






















ORTHOPEDIC SURGERY 
IN VIETNAM 









MEDICAL DEPARTMENT, UNITED STATES ARMY 

SURGERY IN VIETNAM 

ORTHOPEDIC SURGERY 


Editor for Orthopedic Surgery 

Colonel William E. Burkhalter, MC, USA (Ret.) 


by 

Colonel Anthony Ballard, MC, USA (Ret.) 
Colonel Paul W. Brown, MC, USA (Ret.) 
Colonel William E. Burkhalter, MC, USA (Ret.) 
Colonel William W. Eversmann, Jr., MC, USA (Ret.) 
Colonel John A. Feagin, Jr., MC, USA (Ret.) 
Colonel Gerald W. Mayfield, MC, USA (Ret.) 
Colonel George E. Omer, MC, USA (Ret.) 


OFFICE OF THE SURGEON GENERAL 

AND 

CENTER OF MILITARY HISTORY 
UNITED STATES ARMY 
WASHINGTON, D.C., 1994 



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Library of Congress Cataloging-in-Publication Data 


Orthopedic surgery in Vietnam / editor, William E. Burkhalter ; by 
Anthony Ballard ... [et al.]. 

p. cm. — (Surgery in Vietnam) (CMH pub ; 83-7) 

At head of title: Medical Department, United States Army. 

Includes bibliographical references and index. 

1. Orthopedic surgery—Vietnam—history. 2. Vietnamese Conflict, 
1961-1975—Medical care. 3. Orthopedic surgery—United States— 
History. 4. Surgery, Military—Vietnam. 5. Surgery, Military— 

United States. I. Burkhalter, William E., 1928- . II. Ballard, 

Anthony. III. United States. Dept, of the Army. Office of the 
Surgeon General. IV. Center of Military History. V. United States. 
Army Medical Dept. V. Series. VII. Series: CMH pub ; 83-7. 

[DNLM: 1. Orthopedics—history—United States. 2. Orthopedics— 
history—Vietnam. 3. Military Medicine—United States. 4. Wounds 
and Injuries—surgery. 5. Wounds and Injuries—rehabilitation. 

6. Vietnam. 7. United States. WE 168 077 1993] 

RD2111961 .078 1993 

617.3'00973'09597—dc20 

DNLM/DC 93-39914 

for Library of Congress CIP 


CMH Pub 83-7 


First Printing 


For sale by the Superintendent of Documents, Mail Stop: SSOP 
U.S. Government Printing Office 
Washington, D.C. 20402 




MEDICAL DEPARTMENT, UNITED STATES ARMY 


The volumes comprising the official history of the Medical Department of the 
United States Army in Vietnam are prepared by the U.S. Army Center of Military 
History and published under the direction of the Surgeon General and the Chief of 
Military History. These volumes are divided into two groups: (1) the professional, or 
clinical and technical, and (2) medically related subjects. This is the third volume of 
the former group; the first two volumes are entitled “Skin Diseases in Vietnam, 
1965-72,” and “General Medicine and Infectious Diseases.” 


Center of Military History 


Brigadier General Harold W. Nelson, Chief of Military History 
Jeffrey J. Clarke, Chief Historian 
Mary C. Gillett, Chief Clinical History Program 
Colonel William T. Bowers, Chief Histories Division 


Authors 


Anthony Ballard, M.D. 

Colonel, MC, USA (Ret.). Professor of Orthopedics and Rehabilitation, University of 
Miami School of Medicine; Chief, Section of Pediatric Orthopedics, Jackson Memorial 
Hospital, Miami, FL; Director of Orthopedic Residency Education, Department of 
Orthopedics and Rehabilitation, University of Miami/Jackson Memorial Medical Cen¬ 
ter, 1982-90; Commanding Officer, 2d Surgical Hospital, Republic of Vietnam, 1966-67; 
Chief, Orthopedic Service, Tripler Army Medical Center, Honolulu, HI, 1969-71; Chief, 
Orthopedic Service, Fitzsimons Army Medical Center, Denver, CO, 1974-80. 


Paul W. Brown, M.D. 

Colonel, MC, USA (Ret.). Clinical Professor of Orthopedics and Rehabilitation and 
Clinical Professor of Plastic and Reconstructive Surgery, Yale University School of 
Medicine; Consultant in Hand Surgery, Veterans Administration; Chief of Hand 
Surgery, St. Vincent’s Medical Center, Bridgeport, CT; Chief, Division of Orthopedics, 
Fitzsimons General Hospital, 1966-69. 


William E. Burkhalter, M.D. (deceased) 

Colonel, MC, USA (Ret.). Professor and Associate Chairman for Clinical Affairs in the 
Department of Orthopedics and Rehabilitation; Chief, Division of Hand Surgery; De¬ 
partment of Orthopedics and Rehabilitation, University of Miami School of Medicine, 
Miami, FL; Chief of Orthopedics and Chief, Professional Service, 85th Evacuation Hos¬ 
pital, Republic of Vietnam, 1965-66; Chief of Orthopedics, Tripler Army Medical Cen¬ 
ter, Honolulu, HI, 1967-69; Orthopedic Consultant, U.S. Army, Pacific, 1967-69; Chief 
of Orthopedics, Fitzsimons Army Medical Center, Denver, CO, 1969-74. 


William W. Eversmann, Jr., M.D. 

Colonel, MC, USA (Ret.). Chief, Orthopedics, and Chief, Professional Services, 27th 
Surgical Hospital, and Chief, Orthopedic Service, 91st Evacuation Hospital, Republic of 
Vietnam, 1971; Member of teaching staff. Orthopedic Service, Tripler Army Medical 
Center; Assistant Chief and Chief, Orthopedic Service, Fitzsimons Army Medical Cen¬ 
ter until 1983; affiliated with the Iowa Medical Clinic, Cedar Rapids; President, Iowa 
Medical Society, 1992-93. 


Authors 


viii 

John A. Feagin, Jr., M.D. 

Colonel, MC, USA (Ret.). Associate Professor of Orthopedics, Duke University, 1990 
to present; Associate Professor, Biomedical Engineering, Duke University Medical 
Center, 1990 to present; Chief of Orthopedic Surgery, Durham VA Hospital, 1990 to 
present; Clinical Professor of Surgery, University of Health Sciences, Bethesda, MD, 
1989 to present; Chief of Orthopedics, 85th Evacuation Hospital, Qui Nhon, Vietnam, 
1966-67; Team Physician, United States Military Academy, West Point, NY, 1968-72; 
Assistant Chief, Orthopedics, Letterman Army Medical Center, 1972-78; Commander, 
Keller Army Hospital, West Point, NY, 1978-79. 


Gerald W. Mayfield, M.D. 

Colonel, MC, USA (Ret.). Chief of Orthopedics, 121st Evacuation Hospital, Korea, 

1966- 67; Assistant Chief of Orthopedics, U.S. Army Hospital, Camp Zama, Japan, 

1967- 68; Chief of Orthopedics, U.S. Army Hospital, Camp Zama, Japan, 1969-70; 
Teaching Staff, Fitzsimons Army Medical Center, 1971-74; Assistant Chief of Orthope¬ 
dics, Tripler Army Medical Center, 1974-77; Chief of Orthopedics, Straub Clinic & Hos¬ 
pital, Honolulu, HI, 1980-91; Assistant Clinical Professor of Orthopedic Surgery, John 
A. Burns School of Medicine, University of Hawaii, 1977-91. 


George E. Omer, Jr., M.D. 

Colonel, MC, USA (Ret.). Professor of Anatomy, Orthopedics and Surgery; Chairman, 
Department of Orthopedics and Rehabilitation; Chief, Division of Hand Surgery, Depart¬ 
ment of Surgery, University of New Mexico School of Medicine, Albuquerque; Assistant 
Chief, Orthopedic Service, William Beaumont Army Hospital, 1956; Chief, Surgical Ser¬ 
vices, Irwin Army Hospital, 1957-59; Orthopedic Consultant, Eighth U.S. Army, Chief, 
Orthopedics, 121st Evacuation Hospital, Korea, 1959-60; Assistant Chief, Orthopedic Ser¬ 
vice, Fitzsimons General Hospital, 1960-63; Director, Orthopedic Residency Training Pro¬ 
gram and Pathology Courses, Armed Forces Institute of Pathology, 1963-65; Consultant 
in Orthopedic Surgery to the Surgeon General, U.S. Army, Chief, Hand Surgery Center, 
Chief, Orthopedic Service, and Assistant Chief, Department of Surgery, Brooke Army 
Medical Center, 1965-70. 


Foreword 


Many in our society, today and in the past, have found it difficult to reconcile the 
professions of medicine and the military, on the thesis that one exists to maintain life 
and the other to take it. Nothing could be further from the truth. The ultimate goals 
of each are precisely the same: preservation of life, society, and the dignity of man. 

When deterrence fails and war does come, these professions become even fur¬ 
ther intertwined. Medicine must keep the force fit, prevent or treat disease, and re¬ 
pair the injured. Far more is at stake than just the moral obligation to care for our 
wounded. The successful prosecution of warfare demands that we treat and return 
the wounded to battle as quickly as possible. If we do our job well, we become the 
principal source of experienced replacements in wartime. 

Surgeons must not forget the lessons so bitterly learned in previous wars. It is 
time to remember what we did in the Vietnam conflict. We did many things right in 
Vietnam. Perhaps better than in any previous war, we remembered the lessons of the 
past. We managed wounds properly and uniformly, even though there was turbu¬ 
lence in the surgical ranks, as would be expected in a one-year combat zone tour. We 
practiced delayed wound closure from the start and quickly relearned that closure 
by secondary intention is the preferred course in many wounds. We took advantage 
of the helicopter to change the entire system of medical care from one of moving 
treatment facilities to patients to one of moving patients to treatment facilities. This 
allowed us to create the most sophisticated medical facilities ever seen in a combat 
theater. We had ample blood, fluids, and adjunctive antibiotics. Our logistical supply 
line, though extraordinarily long, was effective and essentially unthreatened. We 
used the continuum of care inherent in our system well, evacuating the patients via 
stages from the combat zone to the continental United States (CONUS). 

Since the Vietnam era a new generation of surgeons has been trained. Medicine 
and surgery have advanced technologically, and there has been sufficient time to for¬ 
get the basics of war surgery. To prevent this loss of knowledge, the authors of this 
volume undertook their task. The group of orthopedic surgeons who came together 
in 1972 to write this history knew it would be difficult to combine the historical 
record with a volume useful for orthopedic surgeons in their day-to-day practice. To 
be credible, their statements and conclusions needed to be supported by scientific 
data which had been difficult to collect in a wartime situation. The wide dispersion 
of orthopedic patients throughout CONUS made comprehensive data especially dif¬ 
ficult to retrieve. Therefore, most of the clinical data in the chapters came not from a 
central retrieval system but from records collected by the individual contributors. 
Had centers for hand, peripheral nerve, amputee, and other medical problems been 
established, as would have been ideal, data could have been collected and treatment 
modalities altered on the basis of this experience even during the war. 

The authors of this volume, already distinguished military surgeons and educa¬ 
tors when the book was started in 1972, have each achieved additional honors in sub¬ 
sequent years. The Army Medical Department is fortunate that these leaders in 
American orthopedic surgery completed full careers in Army medicine prior to their 
present important roles in national medicine. 


X 


Professor William E. Burkhalter (Colonel, Medical Corps, retired), the coordi¬ 
nating author/editor, exercised noteworthy leadership in compiling this text. The 
other authors are busy men who have given their time and effort out of loyalty to 
Army medicine and to society. These men were my heroes when I was a young sur¬ 
geon in Vietnam. They remain my heroes today. 

I must commend our medical editor, Lottie Applewhite, formerly of the Letter- 
man Army Institute of Research, who volunteered hundreds of hours of work on 
this volume. Finally, the authors and I thank Dr. Mary Gillett, director of the clinical 
history program at the Center of Military History, for placing this work “at the head 
of the queue.” 


Frank F. Ledford, Jr. 
Lieutenant General , USA 
The Surgeon General 


Preface 


The surgeons who participated in the writing of this history knew each other per¬ 
sonally and professionally while in the military and to varying degrees have kept 
contact following their retirement. Colonel Raymond Bagg, even though his name 
does not appear as an author on any of the individual chapters, was an important 
source of information and follow-up data on patients who passed through the 106th 
General Hospital in Yokohama, Japan. Without this information, including subse¬ 
quent follow-up, very little could have been said about long-term results in certain 
areas of this history. 

This volume could not have come to completion without the efforts of Charles J. 
Simpson, who during the beginning of this volume was the director of the Clinical 
History Program at the Center of Military History in Washington, D.C. His constant 
enthusiastic interest and input made us want to complete this volume more quickly 
than it was done. It was Charlie’s idea to have this really be contemporary history so 
that it could be used in subsequent conflicts and new surgeons might not have to re¬ 
learn the lessons of the past. 

We are all pleased that it is completed. We are sorry that it took so long, but I think 
it represents our true feelings about the management of the patients from the battle¬ 
field through the evacuation system to their final disposition in the United States. 

In addition to Charlie Simpson and the individual physicians responsible for writ¬ 
ing the chapters of this volume, many others were involved. Included, especially, were 
the physicians and nurses who took care of the patients on a day-to-day basis, the or- 
thotist and prosthetist who fabricated the external devices, the physical and occupa¬ 
tional therapists, and, most importantly, the patients themselves. 

In most instances these patients had greater motivation than many of us had seen 
in any patient population. It was easy for most of the physicians to harness this enthu¬ 
siasm and energy in the rehabilitation effort of this group of orthopedic patients. This 
high degree of motivation is responsible for much of the success that we enjoyed in 
managing this group of patients. 

We would like to dedicate this volume to Charles J. Simpson (“Charlie”) and to 
the patients who are the basis of this volume. 


William E. Burkhalter, M.D. 


Introduction 


Dr. William E. (Bill) Burkhalter died before this volume finally emerged from 
the labyrinths of government. He had labored mightily to cajole, coerce, and brow¬ 
beat the coauthors to complete their chapters. That it has been finally published is 
due in large part to his determination—quite typical of his devotion to duty and to 
the patients we all served. 

Sad though his death was, it would be truly tragic if the lessons we learned were 
allowed to lie fallow. With every war we learn something new about wound man¬ 
agement, and yet, with each new war, we seem unable to promptly apply the lessons 
learned from the preceding one. All who are charged with the care of future casual¬ 
ties should carefully read what Dr. Burkhalter has summarized in the last chapter of 
this work. 


Paul W. Brown, M.D. 


Contents 


Chapter Page 

1 The Soldier and His Wound in Vietnam 

(Colonel John A. Feagin,Jr., MC, USA (Ret.)) . 1 

The Milieu. 1 

Care of the Wounded Soldier. 3 

Care of the Soldier’s Wound. 6 

Wound Infection and Antibiotics. 10 

MEDCAP Activities. 16 

2 Penetrating Injuries of the Thigh With Associated Femoral Fracture 

(Colonel William E. Burkhalter, MC, USA (Ret.)) . 21 

Practices During the Vietnam Conflict. 22 

Treatment in Japan. 27 

Treatment in CONUS—Ambulation in the Cast Brace. 30 

Lessons Learned. 32 

3 Penetrating Wounds of the Leg With Associated Fractures of the Tibia 

(Colonel William E. Burkhalter, MC, USA (Ret.)) . 39 

Historical Background. 39 

Treatment in Vietnam. 40 

Treatment After Vietnam. 44 

Recommendations. 52 

4 Wounds of the Hand 

(Colonel William E. Burkhalter, MC, USA (Ret.)) . 55 

Development of Army Hand Surgery. 55 

Conclusions. 80 

5 Wounds of the Foot 

(Colonel Anthony Ballard, MC, USA (Ret.)) . 83 

Treatment Principles. 83 

Specific Injuries. 87 

Recommended Operative Approach to Deep Compartments of 

the Wounded Foot. 102 

Summary. 105 

6 Wounds of Joints 

(Colonel Anthony Ballard, MC, USA (Ret.)) . 107 

Historical Background. 107 

Overall Policy in the Treatment of Joint Wounds. 110 

Wounds of the Knee. Ill 

Wounds of the Hip. 119 

Wounds of the Shoulder. 123 
































XIV 


Chapter Page 

7 Vietnam War Amputees 

(Colonel Gerald W. Mayfield, MC, USA (Ret.)) . 131 

Wounds and Wounding Agents. 131 

Management of Patients With Amputations. 132 

Management of Amputations Classified by Anatomical Site. 137 

Special Prosthetic Considerations. 146 

Lessons Learned. 149 

8 Peripheral Nerve Problems (Colonel George E. Omer, Jr., MC, USA 

(Ret.), and Colonel William W. Eversmann, Jr., MC, USA (Ret.) . 155 

Initial Surgery. 155 

Spontaneous Recovery. 157 

Management of Painful Neuroma in Continuity and Causalgia.... 158 

Surgical Techniques. 166 

Extremity Reconstruction. 170 

Long-Term Follow-up of Combat-Incurred Peripheral Nerve 

Injuries at Fitzsimons Army Medical Center. 182 

Summation. 185 

9 Rehabilitation of the Combat-Wounded Amputee 

(Colonel Paul W Brown, MC, USA (Ret.)) . 189 

Historical Background. 189 

Evacuation Policies and the Patient in the Vietnam War. 191 

Care in CONUS Hospitals. 192 

Rehabilitation: The Challenge. 194 

Motivation and the Rehabilitation Program. 197 

Lessons Learned and Recommendations. 207 

10 Epilogue: General Thoughts on the Management of Orthopedic Casualties 

(Colonel William E. Burkhalter, MC, USA (Ret.)) . 211 

Lessons Learned and Unlearned. 211 

Communication and Consultants. 213 

Continuity of Care and Rehabilitation. 213 

Index. 217 

Illustrations 

Figure 

1 The MedEvac “Huey” helicopter. 2 

2 Evacuation of a wounded soldier. 4 

3 High-velocity gunshot wound of the humerus. 7 

4 Examples of patient-care facilities. 14-15 

5 Elevation to allow circumferential extremity surgical preparation. 23 

6 Tobruk splint used with femoral fractures. 24 

7 Ipsilateral femoral and tibial fracture with contralateral below-knee 

amputation in continuous traction. 25 

8 Cast brace to allow stabilization and use of limb musculature. 30 

9 Moderate soft tissue injuries with femoral fracture and bone loss. 33 




































XV 


Figure Page 

10 Severe soft tissue injury with bone loss. 34-35 

11 Use of an air splint. 41 

12 Example of poor debridement which resulted in below-knee 

amputation. 42 

13 Treatment of tibial shaft fracture with long-leg and Delbet casts. 45 

14 Open fracture with exposed bone and contralateral above-knee 

amputation. 48-49 

15 Middle one-third tibia bone loss. 50-51 

16 Blast injury to hand with skin and bone loss. 57-59 

17 Through-and-through high-velocity wound of a hand with previous 

index ray excision. 61-63 

18 Multiple open fractures with skin loss. 65-67 

19 Viable but unstable index finger following blast injury. 70-71 

20 Bone loss injury to first metacarpal with resultant adduction 

contracture of the thumb. 73-76 

21 Severe explosive injury to the wrist with bone, tendon, and skin loss. . . 78-80 

22 Necrosis of the forefoot following crush injury. 84 

23 Medial plantar wound from bamboo stake penetration into deep 

plantar compartments. 88 

24 Skin incision for exploration of plantar foot compartments, avoiding 

primary weightbearing prominences. 89 

25 Retracted laciniate ligament, exposing posterior tibial. 89 

26 Shotgun wound of the ankle with destruction of the talus and fracture 

of the calcaneus. 92-93 

27 Longitudinal heel-splitting incision to debride infected calcaneus and 

plantar heel wounds. 94 

28 Perforating gunshot wound of the heel. 95 

29 Gunshot wound to the hindfoot with severe damage to the calcaneus 

and nerves and arteries of the heel pad. 96 

30 Chopart amputation with common equivinorus deformity of the 

hindfoot. 99 

31 Loss of lateral rays, compatible with fair foot function. 99 

32 Loss of medial rays, resulting in poor foot function. 101 

33 Use of skin of toes 2-4 to resurface plantar area over metatarsal heads. . 103 

34 Transection of origins of abductor and flexor digitorum brevis muscles. . 104 

35 Willem’s technique of active joint motion in the presence of open 

wounds applied to the elbow.108-09 

36 Treatment of infection following penetrating injuries of the knee 

without significant fractures...116-17 

37 Saggital diagram of a knee in partial flexion, showing spaces that 

sequester effusion and purulent material. 120 

38 Arthrodesis of the shoulder without humeral head. 128 

39 Continuous distal skin traction in open amputations. 135 

40 Severe mid-tarsal gunshot wound converted to Chopart following 

debridement. 140 

41 Temporary plaster blow-knee prosthesis. 141 

42 Use of elastomer foam insert, allowing early prosthetic training. 145 

43 Bent-knee pylon, allowing early ambulation. 147 

44 X-ray evaluation to allow improved prosthesis fabrication. 149 

45 Method of managing painful neuroma in continuity and causalgia .... 162-63 


































XVI 


Figure Page 

46 Surgical scar following surgical sympathectomy. 164 

47 Epineurial repair by freeing and transposing the ulnar nerve. 168 

48 Fascicular bundle nerve grafts of ulnar nerve. 170 

49 Extensor indicis proprius transfer. 172 

50 Tendon transfer of long or ring flexor digitorum superficialis. 173 

51 Application of von Frey monofilament to a digit. 179 

52 Transfer of double neurovascular cutaneous island from ring-little 

web space to thumb-index web space... 181 

53 Amputee ski program, Arapahoe Basin, Colorado. 199 

54 Three-track skiers. 200 

55 Bilateral above-knee amputee skier with “stubby” prostheses. 202 

56 Bilateral above-knee amputee with improvised swim fins. 204 

57 Triple amputee in riding saddle. 205 

58 Amputees at a gallop. 206 


Tables 


Number 

1 Mechanism of injury of 300 patients with fractured femurs. 28 

2 Location and type of femoral fracture. 28 

3 Amputations during first hospitalization for midfoot metatarsal injury, 

Fitzsimons General Hospital, 1966-70 . 98 

4 Amputations or revisions at subsequent hospitalization for midfoot or 

metatarsal injury, Fitzsimons General Hospital, 1966-70 . 100 

5 Results after first hospitalization, open injuries of the foot, 

Brooke Army Medical Center, 1966-69 . 100 

6 Final disposition of patients with knee wounds. 115 

7 Influence of intra-articular fractures on final results. 115 

8 Interval between injury and spontaneous recovery in gunshot wounds. . 157 

9 Time scale in months for spontaneous recovery in gunshot wounds. . . . 158 

10 Summary of upper extermity nerve injuries at Brooke Army 

Medical Center. 158 

11 Causalgia: Nerves involved (1966-70) during Vietnam War. 159 

12 Causalgia: Time of onset of symptoms (1969-70) during Vietnam War. . 159 

13 Causalgia: Causative agent (1966-78) during Vietnam War. 160 

14 Causalgia: Results of treatment (1966-70) during Vietnam War. 160 

15 Vietnam neurorrhaphy related to etiology and level of injury. 166 

16 Vietnam neurorrhaphy secondary suture—specific nerves. 167 

17 Vietnam cases with external neurolysis. 169 

18 Autogenous grafts of major nerves—Vietnam War. 170 

19 Early tendon transfers as internal splints. 174 

20 Median nerve palsy. 174 

21 Radial nerve palsy. 175 

22 Ulnar nerve palsy. 175 

23 Combined low median-low ulnar palsy. 176 

24 Combined high median-high ulnar palsy. 177 

25 Combined high median-radial palsy. 177 

26 Combined high ulnar-radial palsy. 178 






































1 


The Soldier and His Wound in Vietnam 

Colonel John A. Feagin, Jr., MC, USA (Ret.) 

The soldier cannot be separated from his wound. Nor could the soldier and his 
wound be separated from the milieu of the Republic of Vietnam, where medical of¬ 
ficers caring for the combat casualty met both expected and unexpected difficulties. 
All those responsible for the wounded faced the challenges that resulted when the 
world of modern medicine, modern methods of evacuation, and modern weaponry 
encountered the paddies, jungles, and microorganisms of an ancient and tropical 
land. This chapter reflects specifically those experiences shared by Army surgeons 
at the 85th Evacuation Hospital between 1966 and 1968. 

THE MILIEU 

The Republic of Vietnam is a country halfway around the globe from the conti¬ 
nental United States (CONUS) between the latitudes of 9 to 16 degrees north of the 
equator. The terrain, ranging from rice paddies to beautiful narrow valleys, pre¬ 
sented geographic and climatic conditions that complicated the work of the surgeon. 
Heat and humidity were factors. Endemic conditions of filth and disease frequently 
intruded upon basic care of injuries. Soldiers were wounded along waterways where 
human and animal excreta were common. Fevers of unknown origin invaded the 
health of our troops. Even postoperative fevers demanded a malaria smear for dif¬ 
ferential diagnosis. 

A majority of casualties resulted from patrol actions, search and destroy mis¬ 
sions, and helicopter assault missions that took place in areas inaccessible to land- 
based motorized vehicles. The medical service system in Vietnam worked well, for 
the incoming casualties as well as for timely evacuation. From the orthopedist's 
view, the helicopter made many things possible (fig. 1). Since many missions took 
place in daylight, the casualty was usually received within the “golden” six-hour pe¬ 
riod after injury, often within less than thirty minutes. He had been well bandaged 
and splinted, the ride had been smooth, and preliminary diagnoses might well have 
been radioed ahead. If an overload had developed, the flight plan might have been 
changed and the patient diverted to another facility with equal capability, usually 
within easy flight radius. Marines sometimes appeared unannounced, however, 
since they often did not have meshing communications. 

The hospital was well prepared to receive the casualty, beginning with the heli¬ 
pad, which was as much a part of the facility as the surgical suite. The receiving area 
where the patient was resuscitated had intravenous hangers and litter racks. Radio¬ 
logical facilities were comparable to departments in CONUS, and surgical suites 
were well equipped. Gas machines with nitrous oxide, oxygen, and halothane were 
standard. Jet lavage, which might have been beneficial, was not consistently avail- 


2 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 1.—The MedEvac “Huey” helicopter. 

able, but irrigation during debridement was copious. The facilities had good floor 
drainage, and the postoperative area, although unsophisticated, was adequate. Res¬ 
piratory ventilation units were not standard and usually were not available; if a light, 
simple, reliable unit had been developed, it would have proven valuable. Air condi¬ 
tioning, desirable because of the heat and humidity, was usually available in the sur¬ 
gical suites and postoperative areas. Patients who could leave the recovery area were 
sent to nursing units that consisted of forty-bed quonset huts with concrete floors. 

Evacuation after definitive surgical treatment took place after an average four-day 
stay in the postoperative unit, nursing unit, or both, although the holding policy at our 
evacuation hospital was thirty days. The fixed wing flights that usually handled evacu¬ 
ation took off from an immediately adjacent field and were closely coordinated with 
two departures per week for Clark Field, the U.S. Air Force base in the Philippines. 
Liaison with the Air Force was excellent, and the facilities and surgical expertise avail¬ 
able at Clark inspired confidence. Evacuation was discouraged if the casualty was 
febrile, in undue pain, clinically unstable, or unable to tolerate the decrease in p0 2 that 
would occur in flight. Sometimes attendants were sent with the casualty if tubes were 
to be managed or if liaison with Clark was appropriate. Patients were reevaluated, 
treated, and then flown on to Japan or CONUS for further convalescence. 

Most hospitals were at Table of Organization and Equipment (TO&E) strength, 
and the nursing staff of both recovery room and wards was excellent. Orthopedic 
surgeons generally felt, however, that their specialty was inadequately represented 



THE SOLDIER AND HIS WOUND IN VIETNAM 


3 


in relation to the number and type of combat-wounded soldiers and that the TO&E 
was out of date. The supporting staff of specialists, nurses, and enlisted technicians 
was usually well qualified and dedicated to the mission. Teams became close-knit as 
confidence and loyalties grew. Stateside surgical standards were our standards. The 
draftees, whether physicians or enlisted, earned the respect of all. 

The medical service and the quality and extent of care given in the battle area in 
Vietnam received the unstinting praise of Maj. Gen. Spurgeon Neel, the command 
surgeon (1973, 57). Outstanding initial care, rapid evacuation, well-established for¬ 
ward hospitals, readily available whole blood, current surgical techniques, and top- 
notch medical management minimized contamination and morbidity of potentially 
lethal wounds (Neel, 1973, 49). 

CARE OF THE WOUNDED SOLDIER 

The American soldier was reasonably well conditioned and acclimated for the 
tasks in Vietnam. The intermittent nature of the combat and his frequent resorts to 
the Post Exchange and A-rations probably helped maintain his nutritional status. 
Nevertheless, he was chronically dehydrated. Renal colic, even among young sol¬ 
diers, was a common manifestation of the dehydration. Diarrhea was the scourge of 
all. Fevers of unknown origin were common, but the “sick” soldier was rarely com¬ 
mitted to combat. Thus the typical wounded soldier was a healthy young American 
with approximately 17 percent body fat and reasonable cardiovascular fitness, heat 
acclimated, and 10 percent dehydrated. 

When the soldier was wounded, corpsmen on site rendered the first treatment: 
splinting limbs, bandaging other injured parts, and starting intravenous fluid infu¬ 
sion and transfusion of O-positive blood. Fourteen percent of the blood transfused 
in Vietnam was given at forward aid stations (Heaton et al. 1966). Corpsmen also 
summoned “Dust Off,” the code name for medical evacuation throughout the com¬ 
mand (fig. 2). Morphine was not as necessary as it had been in previous conflicts, 
probably because of the smooth and rapid evacuation. Field tags described the care 
at the initial treatment site. Splinting devices, such as wireladder splints or air 
splints, were adequate when combined with traditional field dressings. The MAST 
pressure suit was sometimes available but seldom used. Frequently, the patient was 
taken to a definitive surgical facility, bypassing the battalion surgeon. Triage did not 
assume the importance it had in past conflicts because of limited engagements, the 
prompt availability of the helicopter, the efficiency of the medical regulating officer, 
and the communications accessible to him. 

Resuscitation was empiric and swift. Ringers lactate, 2000 cc., with four ampules of 
sodium bicarbonate, and 10 million units of penicillin were routine while type-specific 
blood was prepared. An indwelling urinary catheter was inserted. Within twenty-four 
hours after arrival at the definitive treatment facility, the wounded soldier received 
tetanus boosters and two to four units of type-specific blood. Intracatheter needles 
were inserted for prompt restoration of fluid through two or three portals. The patient 
usually had a systolic blood pressure of 100-mm. Hg and a pulse less than 100 beats per 
minute. After the patient had had roentgenograms in the radiology department, he 
was moved to the operating room. Following the debridement and other surgical pro- 


4 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 2.— Prompt evacuation increased the wounded soldier’s chances of survival. 

cedures necessary to care for his wounds, he remained in the recovery area, where the 
vital signs were carefully monitored and replacement fluid therapy was continued. 
Critically wounded patients usually had indwelling urinary catheters. Monitoring the 
output volume helped to determine the adequacy of fluid replacement and to steer re- 
suscitative efforts. The air conditioning of the surgical and postoperative suites helped 
minimize further fluid loss of the already dehydrated soldiers and undoubtedly con¬ 
tributed to decreasing morbidity and mortality rates. After he reached a stable condi¬ 
tion, the patient was transferred to one of the hospital’s nursing units. 

Surgeons caring for the soldier immediately after wounding had to be alert to his 
metabolic status, which reflected a complex process still not completely understood 
though better appreciated because of the studies of the United States Army Surgical 
Research Team (Heisterkamp 1970). This research, a testimony to the Surgeon Gen¬ 
eral's concern and insight, has stood the test of time, and the principles that evolved 
from it are now applied by surgeons in every major trauma center. Those portions of 
the report that proved particularly valuable to the orthopedic surgeons in Vietnam 
in the management of the wounded soldier are summarized under such topics as 
treating respiratory insufficiency, arterial hypoxemia after wounding, blood vol¬ 
umes, serum enzymes in combat casualties, and hypoxemia during convalescence. 

Respiratory insufficiency in combat casualties and, subsequently, severe pul¬ 
monary disease were present in 95 percent of casualties who were resuscitated but sub¬ 
sequently died. Lung weight was the single most objective indication of pulmonary dis- 




THE SOLDIER AND HIS WOUND IN VIETNAM 


5 


ease in the casualty at autopsy. Although fat studies were not performed routinely, fat 
embolism was recorded in only four of 100 autopsy reports. The incidence of severe 
pulmonary disease as found in combat casualties at autopsy has not changed in twenty- 
five years. Most patients died with “wet lung.” Data support the suggestion that the 
lung represents a particularly vulnerable target organ for a variety of pathologic stim¬ 
uli. Pulmonary edema can be rapid and pernicious. (Heisterkamp 1970,26-35.) 

Thirty percent of all wounded soldiers and 17 percent of those with wounds in 
the extremities were hypoxemic (p0 2 less than 80-mm. Hg) on admission. Oxygen, 
administered by mask, was beneficial. Failure of tissue oxygenation was a central 
feature of the shock syndrome in combat casualties. Yet cyanosis was never de¬ 
tected in the anemic, vascularly constricted, often muddy casualty. Shock and acido¬ 
sis aggravated arterial hypoxemia and facilitated fat embolism. Microembolic phe¬ 
nomena were suspect (Heisterkamp 1970, 36-59). 

During induction of anesthesia, patients in hemorrhagic shock exhibited bipha- 
sic shifts in serum sodium concentrations. Using succinylcholine during induction of 
anesthesia to the combat casualty in hemorrhagic shock may be lethal. The signifi¬ 
cantly wounded soldier already has a red blood cell deficit that leads to a decrease 
in red blood cell mass and red blood cell survival (Heisterkamp 1970,159-98). 

The effects of massive transfusion in the acutely wounded soldier were observed 
closely. In the wounded, platelets are rapidly decreased. Operative bleeding, in sig¬ 
nificant loss of volume, was not encountered. Prolonged shock rather than transfu¬ 
sion, per se, seemed to trigger disseminated intravascular coagulopathy (DIC). 
Most patients who died had coagulopathies. Episodic, nonlethal DIC probably oc¬ 
curs during recovery from severe trauma and shock as reflected by abnormalities of 
prothrombin and partial thromboplastin time in thrombocytopenia and fibrinolysis 
(Heisterkamp 1970,111—48). 

Serum enzymes, lactic dehydrogenase (LDH) and serum glutamic oxalacetic 
transminase (SGOT) levels were elevated in more than 79 percent of the combat 
casualties at twenty-four hours. Blast injuries of the foot and abdomen were associ¬ 
ated with increased LDH activity; blood transfusions increased SGOT levels. 
Serum glutamic pyruvic transminase (SGPT) is a direct indicator of cellular necro¬ 
sis and rises late. Enzyme elevations suggested that the degree of tissue damage, 
metabolic alterations, or both were greater than may have been obvious at the 
wound site. The SGOT level may be the most sensitive measure of soft tissue 
trauma (Sleeman et al. 1969; Heisterkamp 1970,1-8). 

Oxygen tension was significantly lower in the recovery room period and recov¬ 
ery of oxygen tension was often delayed until the fourth postoperative day. Nasal 
oxygen favorably affected the degree and duration of hypoxemia. Central venous 
pressure was often normal despite acute pulmonary edema. Posttraumatic pul¬ 
monary edema appears to be a disease of multiple etiologies. Factors of prolonged 
shock, massive transfusion, blast injury, and fracture seem to play major roles in this 
pathogenesis (Heisterkamp 1970, 49-96). 

Although we tried to estimate convalescence time, we could not generalize 
about the average period that would be needed because of the many complications 
that could occur following wounding and because of the many types of wounds. A 
patient who had had a laparotomy might be ready for duty in forty-five to sixty 


6 


ORTHOPEDIC SURGERY IN VIETNAM 


days, while one with a gunshot wound that had fractured the femur usually required 
more than one year of convalescence and rehabilitation. 

Rehabilitation was an important part of the wounded soldier's convalescence. 
He benefited both physically and psychologically from the efforts of the physical 
therapists who entered the combat zone in 1967. They provided invaluable assis¬ 
tance to the orthopedic surgeon by improving the supervision of the patients' iso¬ 
metric exercises, efforts to increase the early range of motion of the joints, pul¬ 
monary ventilation, and early ambulation of some amputees. Postoperative goals 
could be established and implemented before the patient was evacuated. 

The proposal made in late 1967 that patients be evacuated directly from Viet¬ 
nam to hospitals in CONUS for convalescence and rehabilitation was subsequently 
discouraged because the casualties arrived too fatigued and too dehydrated from 
the strenuous and lengthy flight. The break at Clark AFB proved effective for rest 
and reevaluation. Approximately 20 percent of the casualties going through Clark 
were given further surgical therapy because of fever, pain, or suspicion of wound 
complication before being sent to hospitals in Japan or CONUS. 

CARE OF THE SOLDIER S WOUND 

Although the circumstances under which they worked were quite different from 
those of military surgeons of earlier conflicts, surgeons treating wounds in Vietnam 
owed much to their predecessors. Debridement in the modern sense was first used 
in the late eighteenth century by Pierre Joseph Desault, who taught the technique 
to his students, among them Napoleon’s great surgeon, Jean Dominique Larrey. In 
the late nineteenth century, Louis X. E. L. Ollier introduced immobilization of the 
limb in a plaster cast in the belief that absolute rest was conducive to healing. Dur¬ 
ing World War I, American surgeon H. Winnett Orr introduced immobilization of 
the limb as part of the treatment program for extremities afflicted with osteomyeli¬ 
tis. The Orr method was not simply immobilization in the correct position and then 
infrequent dressings with a Vaseline pack, but included all the essentials of surgical 
care, including adequate primary drainage, protection of wound against secondary 
infection, and good patient care (Trueta 1943, 31-33, 37). 

Just before the outbreak of World War II, J. Trueta (1943, 39^42) modified Orr s 
fundamental principles. “If, therefore ... the protection of the wound by plaster cast 
can arrest an infection already in progress,” Trueta commented, “surely it must have 
even a better chance of success if applied before the infective process has begun.” 
He reduced the amount of gauze used for drainage, discarded Orr’s use of Vaseline, 
and eventually substituted a very fine mesh gauze. When he published an account of 
his work in 1938, he noted, “When surgeons have a good knowledge of all the details 
of the technique and when the organization is such that they can deal with a steady 
stream of cases instead of sudden overwhelming numbers, results should be as con¬ 
sistently good as is possible within the limitations of human endeavor.” Trueta’s 
book is a definitive work and essential reading for the student of trauma surgery, but 
trauma surgeons should also be acquainted with the contents of the Surgeon Gen¬ 
eral's volumes on the history of orthopedic surgery in World War II (1956, 1957, and 
1962) and the NATO Emergency War Surgery Handbook (1975). 


THE SOLDIER AND HIS WOUND IN VIETNAM 


7 


In the Vietnam conflict, however, high-velocity missiles produced greater tissue 
destruction than any weapon used in this or other wars. (Rich et al. 1967). The time- 
honored formula used to calculate kinetic energy, MV 2 /2, does not completely re¬ 
flect the massive additional damage that might be done by bullets that yaw or disin¬ 
tegrate. Further, the formula does not reflect the effect of cavitation and secondary 
missiles (shattered bone) or the possibility of fractures and neurovascular injuries in 
bodily areas not in direct contact with the wounding agent. The wound caused by the 
high-velocity missile acquires explosive characteristics in itself because the kinetic 
energy of the wounding agent exceeds the elastic limits of the tissues (fig. 3). 



Figure 3.—A high-velocity gunshot 
wound of the humerus. 


Multiple wounds were more common in Vietnam than in previous conflicts be¬ 
cause of the high velocity of lightweight rounds, the rapid fire at close range, and the 
extensive use of mines and booby traps. These wounds were dirtier than in any previ¬ 
ous conflict; a tremendous amount of dirt, debris, and secondary missiles were hurled 
into the wound during the prolonged cavitation phase. Massive contamination chal¬ 
lenged the surgeon to choose between radical excision of potentially salvageable tissue 
and a more conservative approach that might leave a source of infection (Neel 1973). 

The effectiveness of medical treatment for the wounded can be determined 
from the ratio of deaths to deaths plus surviving wounded. For World War II, the 
ratio was 29.3 percent; for Korea, 26.3 percent; and for Vietnam, 19 percent. The 
ratio of killed in action to wounded in action was 1 to 3.1 in World War II; 1 to 4.1 in 
Korea; and 1 to 5.6 in Vietnam. Sixty-five percent of wounds in Vietnam were 
caused by fragments, but 51 percent of the deaths were caused by small arms as 
compared with only 32 percent in World War II and Korea. More than 54 percent of 
the wounds sustained by soldiers in the Army of the Republic of Vietnam weie ex- 


8 


ORTHOPEDIC SURGERY IN VIETNAM 


tremity wounds. Approximately 42 percent of Americans wounded in Vietnam re¬ 
turned to duty (Neel 1973, 51-52). 

Among wounds encountered by orthopedists in Vietnam were those that were 
self-inflicted, usually involving the second toe of the left foot. Because of the close 
range, in these instances, M16 wounds were perforating but not particularly devas¬ 
tating, probably because the bullet had not begun to yaw and entrance and exit 
wounds were quite equal. Approximately 50 percent of these soldiers could be re¬ 
turned to duty in the theater after appropriate debridement and delayed primary 
closure. Orthopedists saw only occasional self-inflicted hand wounds. Since these 
were more severe than the foot wounds, the patient was usually evacuated. 

Regardless of how the wound was inflicted, surgery was usually carried out by or 
under the direction of specialists. Many new lessons had to be learned and old 
lessons relearned because of the high-velocity missiles. We learned to visualize each 
wound as a compartment and to appreciate that each of the structures within the 
compartment had a different tolerance or compliance and a different response to the 
wounding agent. Skin has a high degree of elasticity and a generous blood supply. 
Fascia served only to constrict. Bone shatters like fine china, and yet nerves and ar¬ 
teries accept the shock reasonably well. Occasionally, though, an intact vascular or 
neural tube disguises intimal or fascicular damage within its confines. Decompres¬ 
sion and drainage in high-velocity wounds can be obtained only when incisions are 
carefully planned and encompass almost the length of the involved segment. No bet¬ 
ter guideline for debridement exists than the poem of Sir James Learmonth: “Of the 
edge of the skin/take a piece very thin/the tighter the fascia/the more you should 
slash’er/of muscle much more /till you see fresh gore/and bundles contract/at the 
least impact/leave intact the bone /except bits quite alone.” 

In primary wound care, the debridement procedure augmented with intra¬ 
venous antibiotics and copious lavage was effective. We gave special attention to 
opening the fascia and the compartment of both the upper and lower extremities 
when they were penetrated by high-velocity missiles. Amputation was not done in 
stylized fashion but rather was performed to retain the maximum amount of skin 
and length. Vascular injuries with associated fractures were best handled by a team. 
Fasciotomy was always accomplished if the disruption of the flow was greater than 
six hours. Tourniquets were always in place and were used for the hand and foot 
but were seldom used for the leg or thigh. Tissues were not shifted during the initial 
surgery. Kirschner wires were sometimes used as spacers during the primary de¬ 
bridement. Because of increased cavitation from the high-velocity missiles, more 
extensive compartment decompression relief was needed. This was particularly true 
in the upper extremities where the lacertus fibrosis and carpal tunnel bound their 
respective segments. In the lower extremity, the fascia required incision. After 
surgery, bulky air occlusive dressings were applied to decrease the chances of sec¬ 
ondary contamination and gram-negative septicemia. Sugar tong splints were occa¬ 
sionally used in preference to circular bandages. At the 85th Evacuation Hospital, 
the cast table was an outdated World War II model, but a crude spica could be ap¬ 
plied when one had assistance. 

Physical therapy was initiated before evacuation to promote well-being, retain 
joint motion when feasible, and/or alleviate psychological stress. Skin traction on 
amputee stumps was routine. A self-contained system was used for air evacuation. 


THE SOLDIER AND HIS WOUND IN VIETNAM 


9 


If we suspected that debridement had not been adequate or that infection had de¬ 
veloped. we promptly performed another debridement procedure. Patients with 
temperatures greater than 100.5 degrees F (38.2 degrees C) were not evacuated but 
were returned to surgery. A compromised compartment or area of undue tissue 
tension usually explained the fever or pain. 

Secondary wound care, which included the management of wound closure, 
wound breakdown, wound infection, stabilization of long bone defects, and similar 
problems, was not ordinarily handled in Vietnam. Although reexploration for surgi¬ 
cal complications indicated by fever, pain, excessive drainage, or vascular compro¬ 
mise was encouraged whenever and wherever they appeared, most secondary 
wound care took place after the patient was evacuated to the 106th General Hospi¬ 
tal, in Yokohama, Japan; the U.S. Air Force Hospital at Clark AFB; Tripler Army 
Medical Center in Hawaii; or CONUS. 

Little has been written on secondary wound management, perhaps because of an 
assumption that surgeons have little trouble knowing when and how to proceed. 
Such, however, is not the case. Certainly, delayed primary closure is one of the most 
valuable methods of wound care. Indication for closure, ideally accomplished within 
seven days after injury, is a clean appearance of the wound. But the fact that high-ve¬ 
locity missiles caused larger defects and potential “dead spaces” complicated the sur¬ 
geon's decisions. Thus the adequately debrided wound overlying a fracture frequently 
presented a challenge to the surgeon performing the delayed primary closure. Many 
of the wounds sustained in Vietnam could not simply be closed by reapproximation 
of skin edges. Tension was too great, and the underlying “dead space” offered a fa¬ 
vorable milieu for bacterial growth. Every conceivable type of suture and plastic tech¬ 
nique was applied to the problem: near-far or far-near sutures, subcuticular sutures, 
adhesive bandages, relaxing incisions, muscle slides, and grafts of all natures were 
tried. None was universally successful. Too often the volume deficit was too large to 
be overcome. The solution to this problem was found in the techniques of Trueta. 
who recommended “adequate debridement, augmented by plaster retention of the 
tissues, and await the passage of time. Bacterial flora is self-adjusting, granulation tis¬ 
sue abounds, and wound contracture 'miraculously' closes the deficit” (1943,35). 

Implicit in the guidelines of the NATO Handbook (1958) is a common under¬ 
standing of the criteria of a “clean appearance of the wound.” This determination 
must be based on studies of bacteriologic findings so that decisions can be made on 
a more scientific basis. Periodically, such studies have been done (Marshall et al. 
1976), but Trueta (1943, 54) seems to have been the first serious student of wound 
flora in battle casualties. Certainly, he was the first surgeon to study the effect of oc¬ 
clusive plaster in-depth. 

In the early years of the conflict in Vietnam, surgeons initiated delayed primary 
closure with relish and fervor. Ultimately however, most orthopedic surgeons came 
to the realization that not all wounds over fractures could be closed. The break¬ 
down rate over fractured femurs, for example, was in excess of 50 percent. The 
breakdown seemed to be based more on the size of the deficit than on the wound 
flora, although gram-negative contamination must be suspect because broad-spec¬ 
trum antibiotics encouraged overgrowth of these organisms. As a result, surgeons 
came to place greater reliance on either the occlusive dressing technique for the 
lower leg or grafting for the leg, hand, forearm, and arm. The mesh graft made its 


10 


ORTHOPEDIC SURGERY IN VIETNAM 


appearance during the Vietnam conflict, gaining immediate acceptance and popu¬ 
larity. Thus, a broader therapeutic range seemed acceptable to the surgeon of the 
Vietnam era. Primary wound drainage was usually obtained by an incision of ade¬ 
quate length and the accompanying fasciotomy. Counter incisions were not usually 
recommended. Suction drainage was frequently used beneath the flap of the wound 
closed by delayed primary suture and seemed effective (Trueta 1943, 35). Penrose 
drains were again condemned either for primarily or secondarily closed extremity 
wounds (CINCPAC-1 1967). Packing wounds with gauze often interfered with free 
drainage and was therefore also discouraged. 

WOUND INFECTION AND ANTIBIOTICS 

To prevent impending wound infection as well as treat it when it was already es¬ 
tablished, antibiotic therapy was an important supportive measure. Although much 
has been published about antibiotics in the civilian literature, such is not the case in 
military literature. Penicillin arrived without much of a literary stir in World War II. 
Senior surgeons apparently realized that the quality of wound care, not the antibi¬ 
otics, would determine the end result. Only Hampton (1957) seemed to develop 
new therapeutic regimens based on the protection of antibiotic coverage. He also 
advocated delayed primary internal fixation of fractures, but the experience is still 
not conclusive on this technique. We really do not know whether antibiotics will 
allow early reparative fracture surgery. 

Before the spring of 1944, sulfanilamide drugs were used by our forces in the 
care of war wounds. In mid-1944, when penicillin became available generally, it was 
used in an effort to provide a wider margin of safety for the aggressive surgical pro¬ 
cedure (Hampton, 1957). Blood replacement and antibiotic therapy were consid¬ 
ered merely adjunctive measures to protect living tissue against invasive infection 
(Hampton 1957). In the European Theater of Operations, American soldiers were 
provided with sulfanilamide pills and sulfa crystals in their first aid kits almost until 
the end of the war. They were instructed to take the pills as soon as they were 
wounded and to sprinkle the crystals into the wounds. It was also rather a general 
policy to spread sulfa crystals into the wound at surgical closure. Both of these prac¬ 
tices were eventually abandoned (Cleveland 1956). 

Sulfanilamide and penicillin helped broaden the scope of surgery, but surgeons 
using them emphasized their protective rather than their prophylactic or curative 
aspects. Unfortunately, antibiotics gave surgeons a feeling of confidence in delayed 
primary closure of wounds (Cleveland 1956). Cleveland reported that in World War 
II, osteomyelitis subsequent to open long bone fractures occurred in 5.4 percent of 
2,152 wounds in the European theater. There is no proof, however, that the inci¬ 
dence of serious wound infections in his series was substantially reduced by the use 
of either sulfonamides or penicillin. The remarkable freedom from infection that 
was enjoyed during World War II should be attributed chiefly to adequate debride¬ 
ment plus the liberal use of whole blood to replace blood rather than to the use of 
the new agents (Cleveland 1956). 

During the Korean War, a broad spectrum of antibiotics was available, but no 
new techniques were introduced or policies established. Battle casualties in Korea 


THE SOLDIER AND HIS WOUND IN VIETNAM 


11 


suffered less wound infection than casualties in previous wars. Clostridial organ¬ 
isms were present in approximately 46 percent of wounds at the time of debride¬ 
ment. The beneficial and protective effects of antibiotics in minimizing Clostridial 
infection (Artz et al. 1956) suggested that antibiotic therapy might influence both 
aerobic and anaerobic flora. 

Records to substantiate all observations on orthopedic wound infection in the 
Vietnam War do not exist, since few longitudinal studies have been conducted that 
could accurately document them. The incidence of chronic osteomyelitis following 
the Vietnam conflict is not known, but two reliable articles (Brown and Urban 
1969; Freeland and Mutz 1976) reflect successful spontaneous closure of infected 
long bone nonunions by debridement, ambulation, and weightbearing plaster aug¬ 
mented by posterior bone graft. Nonunion and chronic osteomyelitis concerned us, 
but such problems were usually resolved between eighteen and twenty-four months 
following wounding (Brown and Urban 1969). 

The experience gained with leaving joint and hand wounds open reduced infec¬ 
tion to an all time low in anatomic areas where it had historically been common and 
disastrous. The classic article by Burkhalter et al. (1968) indicated an infection rate 
of 2.2 percent. A long-term report on open joint wounds does not exist, although 
Davis (1970) stated his optimism about the prognosis of the patients. Infection was 
inevitable in hip joint wounds associated with intra-abdominal wounds. A team ap¬ 
proach was lifesaving. Drainage of the joint must be accompanied by appropriate 
general surgical care of the visceral injury that also had drainage and diversion 
(CINCPAC-1 1967). These potentially lethal wounds must be recognized early. 

Wound infection in amputation stumps has been well documented (Keblish et al. 
1970). Stumps were often edematous and infected, and by the time they were exam¬ 
ined after the patients were evacuated from Vietnam, their skin edges had retracted. 
Skin traction had been frequently ignored, interrupted, or ineffectively applied en 
route. At Valley Forge General Hospital, Pennsylvania, the orthopedic team initi¬ 
ated a dynamic program of early ambulation in spite of open stump wounds. 

By the time of the Vietnam War, orthopedic surgeons recognized that none of the 
antibiotics were substitutes for adequate surgery. They were the beneficiaries of 
World War II and Korean experiences as well as of the guidelines stated in the NATO 
Emergency War Surgery Handbook (1958). The handbook noted that “antibiotic 
therapy is an important supportive measure which is employed for the prevention of 
impending infection or the treatment of established infection, but its role is limited in 
these objectives. It is not a primary therapeutic measure.” Topical antibiotics had not 
grown in favor since their dispensation in World War II, except when used for burns. 
An in-depth study by Noyes et al. (1967) reflected the historical perspective as well as 
a clinical trial of Sulfamylon. They reported that neither the qualitative nor the quan¬ 
titative bacterial flora of patients treated with Sulfamylon changed when compared 
with the flora of untreated wounds. Furthermore, none of the antimicrobial regimens 
tested prevented proliferation ol Pseudomonas species. 

Little mention was made of antibiotics in discussions of the military surgical prac¬ 
tices of the U.S. Army, Vietnam (USARV). After a consultant visit to Japan and 
Southeast Asia in November 1966, Col. Robert M. Hall, MC, Orthopedic Consultant 
to the USARV Surgeon, failed to mention antibiotics or to make specific recommen¬ 
dations for their use (Hall 1966). Moreover, command guidance was limited concern- 


12 


ORTHOPEDIC SURGERY IN VIETNAM 


ing the use of new broad-spectrum antibiotics, the selection of appropriate agents to 
counter gram-negative overgrowth and resistant strains, and the adverse effects, such 
as nephrotoxicity and ototoxicity, induced by antibiotics. Heaton et al. (1966), how¬ 
ever, commented on the use of antibiotics in joint wounds, noting that “antibiotic pro¬ 
tection is mandatory as pyarthrosis is a great danger in these large avascular tissues.” 

No orthopedic recommendations about antibiotics were made at the first Com¬ 
mander in Chief, Pacific (CINCPAC), Surgical Conference (20-25 May 1967). The 
consensus of the attendees was that joint wounds must be covered by antibiotics, al¬ 
though in the fresh, well-debrided extremity wound, antibiotics were not indicated. 
The conference coordinator did, however, recommend comparing various antibi¬ 
otic regimens in addition to the penicillin-streptomycin combinations, indicating a 
change from the old penicillin-streptomycin regimen, particularly with heavier cov¬ 
erage against gram-negative organisms (Artz et al. 1956). 

By the time of the fourth CINCPAC Surgical Conference (16-19 February 
1970), we were already aware that antibiotics such as kanamycin, neomycin, strep¬ 
tomycin, and polymixin B caused respiratory depression or apnea in our patients 
when used as lavage in body cavities. Toxic complications associated with antibi¬ 
otics had been brought to our attention by Col. T. J. Whelan, MC, (1968) in a letter 
circulated from Tripler Army Medical Center to the Vietnam theater in 1968. 

The fourth CINCPAC conference recommended prophylactic antibiotics and 
penicillin in large doses. Surgeons could use broad-spectrum antibiotics at their discre¬ 
tion. but they were cautioned that wound cultures and recultures should guide subse¬ 
quent antibiotic use. This conference also addressed antibiotics and sepsis, noting: 

Infections have been frequent sequelae of wounds throughout the history of 
military medicine. Adequate debridement, immunization, and antibiotics have sig¬ 
nificantly reduced the incidence of wound complications such as gangrene, tetanus, 
and streptococcal cellulitis. However, massive infection in wounds created by 
weapons of modern warfare (e.g., high velocity missiles) and primitive warfare 
(e.g., punji sticks) remains a major problem at all levels of medical care, in-country, 
off-shore, and in CONUS facilities. 

Among the antibiotics used in Vietnam, the most common were penicillin and 
streptomycin, but both were ineffective against microorganisms in more than 50 
percent of the wounds of patients evacuated from Vietnam. All microorganisms 
cultured were sensitive to Mandelamine. The success of penicillin in vivo seemed to 
be dose-dependent. Our experience showed that it should be administered fre¬ 
quently with perhaps as much as 20 million units of penicillin, continuous intra¬ 
venous drip, given for twenty-four hours (Matsumoto 1968). 

The operating surgeon should have knowledge of the type or extent of wound con¬ 
tamination in order to select the appropriate antibiotic, but operating surgeons and the 
supporting laboratory rarely have time to make adequate bacteriologic determina¬ 
tions while they are caring for wounded patients. Such information should come from 
a research team. A beginning was made by the Walter Reed Army Institute of Re¬ 
search (WRAIR) team (Matsumoto 1968). Nevertheless, although broad-spectrum 
antibiotics were available late in the Vietnam conflict and antibiotics were an impor¬ 
tant adjunct in the care of Vietnam wounded, they neither mitigated nor modified the 
basic concepts of war surgery in the thirty-five years since their introduction. 



THE SOLDIER AND HIS WOUND IN VIETNAM 


13 


Wound infection must be considered not only as a response of soft tissue and 
bone to wounding but also as a response to environment and contaminating factors 
introduced in the geographic area. Thus, in the management of wounds and in the 
selection of antibiotics, quantitative microbiology proved to be a reliable and valu¬ 
able diagnostic aid that had considerable influence on surgical decisions. In patients 
with fewer than 10 5 bacteria per gram of tissue, most wounds healed without a 
wound infection. In those patients demonstrating greater than 10 5 organisms per 
gram of tissue, infection was usually present. A team developed a rapid quantita¬ 
tion technique for determining the magnitude of wound contamination that will be 
considered for secondary wound management in future conflicts (Marshall et al. 
1976). The serious student must review the works of G. T. Rodeheaver, Ph.D. (Uni¬ 
versity of Virginia, Medical Center, Charlottesville, Virginia), who has applied 
quantitative microbiologic determinations to civilian wounds. 

Wound studies in Korea revealed a large percentage containing pathogenic aer¬ 
obes and anaerobes (Lindberg 1955). In a group of 175 positive cultures from 112 
wounds, 13 species of bacteria were identified (Artz et al. 1956). Forty percent were 
contaminated by Clostridia species, which were sensitive to various antibiotics 
(Heggers et al. 1969). The most frequently identified bacteria were Staphylococcus 
aureus , Aerobacter aerogenes , Pseudomonas , and Proteus. The Surgical Research 
Team (Artz et al. 1956) pointed out that if routine antibiotics are to be used, peni¬ 
cillin is not the drug of choice. 

The most common microorganisms found in the Vietnam combat casualties sus¬ 
pected of causing morbidity and mortality were Staphylococcus aureus (29.2 percent), 
Pseudomonas aeruginosa (18.3 percent), and Escherichia coli (17.3 percent) (Mat- 
sumoto 1968). Blood cultures from sixty-five cadavers revealed nineteen positive cul¬ 
tures. The most common organisms in this instance were Pseudomonas aeruginosa 
and Klebsiella pneumoniae. The team found no anaerobic microorganisms and con¬ 
cluded that the debridement in this study was adequate. Although all surgeons were 
concerned with gram-negative overgrowth and emergence of resistant strains, little 
objective data have been found to substantiate the perceived problem. 

Serratia marcescens was a striking finding in blood cultures in Vietnam. Since it 
is an airborne organism, surgeons, aware of possible virulence, demanded frequent 
blood cultures and meticulous respiratory care of wounded patients on assisted 
ventilation. The medical and surgical staffs pooled their expertise in the effort to 
prevent and manage sepsis induced by Serratia marcescens. It became clear to both 
internists and surgeons that attention to good infection control practice was of 
prime importance from the outset in the hospital environment at combat support 
facilities. This principle was even more important when these hospitals began to 
serve as fixed installations in support of an active combat role. Since effective bac- 
teriologic analysis was critical to medical support of combat operations, plans to 
provide it had to be made early in the course of planning for the establishment of a 
relatively fixed hospital. Although this approach reflected the view of military in¬ 
ternists and surgeons in Vietnam, medical officers in CONUS also employed it 
when caring for patients with melioidosis (Buchman et al. 1973). 

Extrapulmonary melioidosis, a disease manifesting itself as an orthopedic prob¬ 
lem. had received little attention until the French and then the Americans were ex¬ 
posed to the soil and rice paddies of Southeast Asia (Buchman et al. 1973). It was a 


14 


ORTHOPEDIC SURGERY IN VIETNAM 



















THE SOLDIER AND HIS WOUND IN VIETNAM 


15 




Figure 4 -In an attempt to control dust, heat, humidity, and the mosquito, facilities 
for patient care were improved from tents, to Quonset huts, to inflatable hospitals. 





























16 


ORTHOPEDIC SURGERY IN VIETNAM 


gram-negative infection with an extrapulmonary form. The laboratory had to be alert 
for Pseudomonas pseudomallei, and the surgeon had to be aware of the possibility of 
infection by this organism. Since 1966, at Valley Forge General Hospital, seventy-one 
patients have been treated for melioidosis with no fatalities. Sixteen of the patients 
with melioidosis as an extrapulmonary disease were the subject of a report by Buch- 
man et al. (1973). Prolonged antibiotic therapy with tetracycline was essential. 

Another unusual manifestation of bacteriologic organisms was seen in immer¬ 
sion foot. Combat soldiers experienced epidemics of distinctive warm-water skin in¬ 
jury called “paddy foot,” a variant of warm-water immersion foot. The immersion 
foot is caused by interaction of several factors: principally, changes brought about in 
the resistance of the skin to infection because of long exposure to contaminated 
water; damage to the skin generated by wearing boots and socks; presence of etio- 
logic organisms in the water and the environment; and increased temperature of 
the tropical environment. Akers (1974a and 1974b) has reported on the natural his¬ 
tory, epidemiology, and field experiments of paddy foot. 

The key to dealing with immersion foot was prevention. Rest, elevation, and 
therapeutic use of antibiotics were essential to the treatment. The jungle boot 
seemed to be relatively effective in drying itself and protecting the bottom of the 
foot from minor penetrating blows, but it did not provide much ankle or foot sup¬ 
port. Callosities and immersion foot sometimes required evacuation to in-country 
convalescent hospital facilities, but out-of-country evacuation was seldom neces¬ 
sary. Most soldiers returned to their units after five to seven days of treatment. 

Gas gangrene and tetanus were almost nonexistent in Americans wounded in 
Vietnam. The rarity of clinical gangrene in these patients cannot be explained entirely 
on the basis of rapid evacuation, early debridement, or timely antimicrobial therapy 
(Noyes et al. 1967). The rarity of gas gangrene is even more surprising in view of the 
extensive arterial repairs that were attempted. I did not see or hear of a case of 
tetanus in an American casualty in Vietnam, but we routinely gave 0.5 cc. tetanus tox¬ 
oid boosters to each patient admitted to the primary treatment facility. Certainly war 
wounds without concomitant complications of these two ill harbingers represented 
surgical progress. Both tetanus and gas gangrene were seen in the Viet Cong casualty, 
who frequently arrived moribund and tetanic. These patients were extremely toxic; 
pulse was usually greater than 140 per minute. Even the most heroic measures sel¬ 
dom saved a limb or life. Occasionally, with intensive and dedicated supportive mea¬ 
sures, we were successful in treating a Viet Cong casualty with tetanus (Brown 1974). 

MEDCAP ACTIVITIES 

Wounded soldiers constituted the principal concern of Army orthopedic sur¬ 
geons in Vietnam, but Vietnamese civilians also benefited from the presence of 
U.S. medical officers in their country and the assistance rendered through Medical 
Civic Action Program (MEDCAP) activities. Although little mention is made of 
specialty MEDCAP care, the reconstructive bent of the orthopedic surgeon is such 
that considerable specialty care took place at all levels (fig. 4). Reconstructive pro¬ 
cedures for poliomyelitis, leprosy, congenital deformities, and civilian war wounds 
were undertaken, when feasible, at almost every hospital with an orthopedic sur- 


THE SOLDIER AND HIS WOUND IN VIETNAM 


17 


geon. This type of care, which Vietnamese surgeons usually looked on as interest¬ 
ing but complex and impractical under the wartime circumstances, would not other¬ 
wise have been available and was gratifying to both patient and surgeon. It was re¬ 
grettable that, because of limited communications, reconstructive techniques could 
not be shared with Vietnamese surgeons. 

As a rule, continuity of MEDCAP care was nearly impossible. The most notable 
exception was at Qui Hoa Leprosarium, five miles from Qui Nhon, to which MED¬ 
CAP orthopedists went regularly every week from 1966 to 1971. American physi¬ 
cians performed surgical procedures, including limited amputation, posterior tibial 
tendon transfers, reconstructive hand surgery, neurolysis, and transfers of the ulnar 
and peroneal nerves (White and Feagin 1972). The regularity and dependability of 
such visits throughout this period resulted in a much higher than usual standard of 
medical care for the patients with leprosy in that beautiful valley and left a lasting 
mark on a small community (White and Feagin 1972). 

The situation—treating the soldier wounded in Vietnam—presented many chal¬ 
lenges to the orthopedic surgeon. The heat, the humidity, the character of the coun¬ 
tryside, and the nature of the wounding agents all influenced care and procedures. 
Helicopters made rapid evacuation and prompt treatment possible regardless of 
terrain, and air conditioning facilitated the work of surgeons in the operating rooms 
of the hospitals receiving the wounded. Whole blood was readily available, and the 
orthopedic personnel and supporting staff rendered outstanding initial care. As a 
result, contamination and the morbidity of potentially lethal wounds were minimal. 
As General Neel pointed out in 1973, the soldier wounded in Vietnam received “a 
quality of care superior to that in any previous conflict” (1973, 58). 

REFERENCES 

Akers, W. A. 1974a. Paddy foot: A warm water immersion foot syndrome variants. 

Part I. The natural disease, epidemiology. Military Medicine 139:605-12. 

Akers, W. A. 1974b. Paddy foot: A warm water immersion foot syndrome variant. 

Part II. Field experiments, correlation. Military Medicine 139:613-18. 

Artz, C. P. 1956. Battle casualties in Korea; studies of the Surgical Research Team. 
Volume III. The battle wound; clinical experiences. Army Medical Service Grad¬ 
uate School. Walter Reed Army Medical Center. Washington: GPO. 

Beyer, J. C. 1962. Wound ballistics in World War II. Supplemented by experiences 
in the Korean War. Office of the Surgeon General, Department of the Army. 
Washington: GPO. 

Brav, E. 1962. Traumatic dislocation of hip. Army experience and results over a 
twelve-year period. Journal of Bone and Joint Surgery 44-A:l 15-34. 

Brown, P. W„ and Urban, J.G. 1969. Early weightbearing treatment of open frac¬ 
tures of the tibia. Journal of Bone and Joint Surgery 51-A:59-75. 

Brown, P. W. 1974. Gas gangrene in a metropolitan community. Journal of Bone 
and Joint Surgery 56-AT445-51. 

Buchman, R. J.; Kmiecik. J. E.; and LaNoue, A. M. 1973. Extrapulmonary melioi¬ 
dosis. American Journal of Surgery 125:324-27. 

Burkhalter, W. E.; Butler, B.; Metz, W.; and Omer, G. 1968. Experiences with de¬ 
layed primary closure of war wounds in the hand in Vietnam. Journal of Bone 
and Joint Surgery 50A:945-54. 


18 


ORTHOPEDIC SURGERY IN VIETNAM 


Cleveland, M. 1956. Orthopedic surgery in the European Theater of Operations. Of¬ 
fice of The Surgeon General, Department of the Army. Washington: GPO. 

CINCPAC-1. 1967. Commander in Chief, Pacific. First CINCPAC Conference on 
War Surgery. Tri-service surgical conference conducted at John Hay Air Base, 
Baguio, the Philippines, 20-25 May 1967. Incl with cover ltr, J.S. Cowan, 
RADM USN, CINCPAC Medical Officer, 12 Jul 1967. 

CINCPAC-4. 1970. Commander in Chief, Pacific. Fourth CINCPAC Conference 
on War Surgery. Tri-service conference conducted in Tokyo, Japan, 16-19 
February 1970. Incl with cover ltr, Frank B. Voris, M.D., RADM USN, CINC¬ 
PAC Surgeon, 2 Mar 1970. 

Davis, G. L. 1970. Management of open wounds of joints during Vietnam War. A 
preliminary study. Clinical Orthopedics 68:3-9. 

NATO Emergency war surgery handbook. 1958. Department of Defense. Washing¬ 
ton: GPO. 

NATO Emergency war surgery handbook. 1975. 1st U.S. revision. Washington: GPO. 

Feagin, J. A. 1967. The use of knee joint catheters in penetrating wounds of the 
knee. Interim report presented at the Society of Military Orthopedic Surgeons. 
Denver, Colorado: Fitzsimons Army Medical Center, October 1967. 

Feagin, J. A., and White, A. A. 1973. Volkmann’s ischemia treated by transfibular 
fasciotomy. Military Medicine 138:497-99. 

Freeland, A. E., and Mutz, S. B. 1976. Posterior bone-grating for infected ununited 
fracture of the tibia. Journal of Bone and Joint Surgery 58:653-57. 

Hall, R. M. Letter, 16 Nov 1966, AVCA-MB-GA-8FH to Surgeon, U.S. Army 
Vietnam, APO 96307, sub: Orthopedic consultants’ visit, 7-14 Nov 1966. 

Hampton, O. P. 1946. Delayed internal fixation of compound battle fractures in the 
Mediterranean Theater of Operations: Follow-up study in Zone of Interior. An¬ 
nals of Surgery 123:238-75. 

Hampton, O. P„ Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Oper¬ 
ations. Mather Cleveland, ed. Office of The Surgeon General, Department of 
the Army. Washington: GPO. 

Heaton, L. D.: Hughes, C. W.; Rosegay, H.; Fisher, G. W.; and Feighny, R. E. 1966. 
Military surgical practices of the United States Army in Vietnam. A mono¬ 
graph. Current problems in surgery. Chicago: Year Book Medical Publishers, 
Inc., 1966. 

Heggers, J. P.; Barnes, S. T.; Robson, M.C.; Ristroph, J. D.; and Omer, G. E., Jr. 
1969. Microbial flora of orthopedic war wounds. Military Medicine 134:602-03. 

Heisterkamp, C. A. Ill, comp, and ed. 1970. Activities of the US Army Surgical Research 
Team , WRAIR—Vietnam (tech rpt, 17 Jun 1967 to 20 Jan 1968, prepared for the 
U.S. Army Medical Research and Development Command). Washington: GPO. 

Henry, A. K. Extensile exposure. 2d ed. 1962. Edinburgh and London: E. W. Living¬ 
stone. (Books by the same author and with the same title have been published by 
Williams and Wilkins, in Baltimore, 1957 and Churchill in London, 1970). 

Keblish, P. A.; LaNoue, A. M.; and Deffer, P. A. 1970. Early management of the 
lower extremity battle-incurred amputee at Valley Forge General Hospital 
(U.S.A.) Reproduced from presentation. Eastern Orthopedic Association 
Meeting, November 1970, pp. 87-91. 

Lindberg, R. B.; Wetzler, T. F.; Marshall, J. D.; Newton, A.; Strawitz, J. G.; and 
Howard, J. M. 1955. Bacterial flora of battle wounds at the time of primary de¬ 
bridement. Study of Korean battle casualty. Annals of Surgery 141:369-74. 


THE SOLDIER AND HIS WOUND IN VIETNAM 


19 


Marshall, K. A.; Edgerton, M. T.; Rodeheaver, G. T.; Magee, C. M.; and Edlich, R. 
F. 1976. Quantitative microbiology. Its application to hand injuries. American 
Journal of Surgery 131:728-33. 

Matsumoto, T. 1968. Ltr, USAMCJ-249-WRAIR to Maj Gen J. M. Blumberg, com¬ 
manding, U.S. Army Medical Research and Development Command, 27 Nov 
1968, sub: Progress Report (1 Sep-20 Nov) of the WRAIR Surgical Team (No. 3). 

Meroney, W. H., ed. Battle casualties in Korea: studies of the Surgical Research 
Team, volume IV. Post-traumatic renal insufficiency. Washington: GPO. 

Neel, S. 1973. Medical support of U.S. Army in Vietnam , 1965-1970. Washington: GPO. 

Noyes, H. E.; Nguyen, H. C.; Lee, T. L.; Duong, H. M.; Punyashthiti, K.; and Pugh, 
C., Jr. 1967. Delayed topical antimicrobials as adjuncts to systemic antibiotic 
therapy of war wounds; Bacteriologic studies. Military Medicine 132:461-68. 

Rich, N. M.; Johnson, E. V.; and Dimond, F. C., Jr. 1967. Wounding power of mis¬ 
siles used in the Republic of Vietnam. Journal of the American Medical Associa¬ 
tion 199:157, 160,161,168. 

Sleeman, H. K.; Simmons, R. L.; and Heisterkamp, C. A. 1969. Serum enzymes in 
combat casualties. Archives of Surgery 98:272-74. 

Treuta, J. 1943. The principles and practice of war surgery. St. Louis: C. V. Mosby Co. 

Whelan, T. J., Jr. 1968. Ltr to Lt. Col. Clyde N. Herrick, 31 Jan 68, sub: A Warning 
in the Use of Irrigation—Aspiration Techniques for Topical Neomycin, Baci¬ 
tracin and Polymixin B Administration. 






2 


Penetrating Injuries of the Thigh 
With Associated Femoral Fracture 

Colonel William E. Burkhalter, MC, USA (Ret.) 

In both World Wars, a battle-incurred compound fracture of the femur was re¬ 
garded as one of the most serious skeletal injuries a soldier could sustain (Hampton 
1957, 137). In World War I, 971 or (25 percent) of the 3,850 soldiers with femoral frac¬ 
tures and penetrating wounds of the thigh died. Fractures of the femur constituted ap¬ 
proximately 24 percent of the 16,339 recorded World War I battlefield fractures. The 
mortality figures in World War II were much lower. One study indicated only 7.9 per¬ 
cent of all deaths were attributed to compound fractures of the lower extremity 
(Hampton 1957). During the Vietnam conflict fractures of the femur continued to be 
one of the most costly injuries sustained by the combat soldier, in terms of the length of 
hospitalization and residual functional impairment. Direct comparisons of the three 
conflicts are impossible because of changes in categories and classification systems. 

The concepts and practices for treatment of combat casualties with penetrating 
wounds of the thigh and a fractured femur changed markedly from war to war. Dur¬ 
ing World War I, splinting rather than plaster was generally emphasized, in order to 
maximize the desired freedom of joint movement. Infection was treated by local ap¬ 
plications of such agents as bismuth subnitrate, iodoform, and paraffin (BIP) or by 
the elaborate irrigation ritual of the Carrel-Dakin method. Evaluation of the results 
indicated a high incidence of malunion, nonunion, and infection, as well as exces¬ 
sively high rates of amputation and fatality. After the war, the Carrel-Dakin method 
fell into disuse and was replaced by the closed plaster technique, usually credited to 
H. Winett Orr, whereby the wound was left open to allow drainage and the limb was 
placed in a plaster cast with skeletal fixation of the fracture. The objective of this 
method was to prevent the trauma and reinfection that was so prevalent with fre¬ 
quent changes of dressings. It was a one-stage program for management of the com¬ 
bat-incurred compound fracture of the femur with associated soft tissue injuries. The 
first wartime test of the closed plaster technique came during the Spanish Civil War. 
Trueta, as cited by Hampton (Hampton 1957, 53) reported excellent results, but 
United States surgeons during the North African campaign found the program un¬ 
workable (Hampton 1957, 55). The theoretical benefits of the technique were 
negated by complications caused by moving patients from forward to rear hospitals. 
Patients became febrile, plaster disintegrated or proved ineffective, circulatory prob¬ 
lems arose, transfixion pins broke, and infection set in, to name a few. By early 1944, 
the practice had been largely discontinued. 

With the failure of the closed plaster technique. Army surgeons in the Mediter¬ 
ranean theater turned to the delayed primary closure of “clinically clean” wounds. 
The bacteriological culture reports that had been relied for twenty-five years were 


22 


ORTHOPEDIC SURGERY IN VIETNAM 


abandoned because they required extensive laboratory assets and multiple changes 
of dressings. The first step in compound fracture management was now limited, for 
the most part, to wound exploration and debridement. At that time, care of the 
fractured femur was limited to correction of gross malposition and splinting for 
transportation. When the patient was in a fixed hospital, during the “golden pe¬ 
riod” for fracture management, usually four to seven days after wounding, he un¬ 
derwent a second surgical procedure. Performed under anesthesia, it involved fur¬ 
ther debridement of necrotic tissue, irrigation, fracture reduction, delayed primary 
closure, drainage conduits, antibiotic therapy, traction, splinting, and casting. The 
patient was prepared for return to the Zone of the Interior. 

World War II military surgeons who treated patients with penetrating injuries to 
the thigh accompanied by fractured femurs expected prolonged recumbency with 
resultant inanition, muscle atrophy, and fibrous ankylosis of joints. Their reports 
(Brav and Fitts 1946; DeLorme et al. 1950) indicated that the natural history of the 
fracture healing required twenty-four weeks before the patients could begin ambu¬ 
lation. Only 30 percent of these patients were expected to have ninety degrees or 
more of knee flexion. Soto-Hall and Horwitz (1946) reported a series of 122 frac¬ 
tures in which 86 percent of the fractures united, 27 percent remained infected with 
definite evidence of osteomyelitis, and 33 percent had limited knee extension. Five 
percent of these patients refractured the femurs. 

PRACTICES DURING THE VIETNAM CONFLICT 

The basic principles of debridement, delayed primary closure, and fracture 
management did not change dramatically from World War II to Vietnam. Techno¬ 
logical advances and the availability of broad-spectrum as well as gram-negative 
and gram-positive specific antibiotics did little to alter the criteria and priorities for 
management of fractures associated with penetrating wounds of the thigh. 

Femoral shaft fractures secondary to penetrating injury posed massive probems for 
combat surgeons. The wound took precedence over the fracture at the initial surgery. 
Following initial surgery, the limb was splinted to prevent further trauma to surround¬ 
ing soft tissue. Only after absolute wound control did physicians become concerned 
about reduction of the fracture. Fracture of the femur associated with severe penetrat¬ 
ing wounds required more than one surgical exploration and wound debridement. 

Initial treatment at the hospital began with resuscitative measures and general 
examination carried out in the triage area. Although examination of the wound was 
not done in the triage area, a search was made for an exit wound (because of the 
possibility of an intra-abdominal course of the bullet with associated injuries in this 
area) and for associated vascular or nerve injuries. 

With the limb splinted and resuscitation proceeding, roentgenograms were ob¬ 
tained in two planes. Constant monitoring of the efficacy of resuscitation and obser¬ 
vations for signs of deterioration continued. If the patient was in severe difficulty, he 
was sent immediately to the operating room. If he was not, after he had received ad¬ 
equate blood replacement and his vital signs had been stabilized, he was sent in 
order of triage-determined priority. Once the patient was in the operating room, the 
surgeon and his team removed the splint and placed a Steinmann pin through the 


PENETRATING INJURIES OF THE THIGH 


23 


tibial tubercle. If suspension equipment was available or could be improvised, the 
limb was suspended by the pin so that both hip and knee were in 90 degrees of flex¬ 
ion. This allowed traction to the femoral shaft fracture during preparation of the 
limb, draping of the limb, and actual surgery of exploration and debridement. The 
traction reduced further soft tissue injury during the usual manipulative portion of 
the prepping, draping, and debridement of the thigh wound (fig. 5). 



Figure 5.—Elevation such as this al¬ 
lowed circumferential extremity sur¬ 
gical preparation and, in case of as¬ 
sociated femoral fracture, stabilized 
the fracture and reduced soft tissue 
injury during surgical preparation 
and debridement. 


Since excessive bleeding often occurred in patients with partially lacerated ves¬ 
sels when clots were disturbed, ready access to the common femoral artery could 
prevent considerable blood loss. Therefore, circumferential prepping and prepping 
of the groin were necessary for care of the wound as well as for immediate access to 
the common femoral artery in the event that excessive bleeding occurred during 
wound exploration. 

Longitudinal wound extension allowed exploration of the depths of the wound 
and required considerable knowledge of cross-sectional anatomy. Since wound de¬ 
bridement was time consuming and resulted in considerable blood loss, blood for 
transfusions had to be available if surgeons were to perform optimal surgical explo¬ 
ration. At the conclusion of exploration and debridement, fine mesh gauze was ap¬ 
plied directly to the wound, which was left open. 




24 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 6.—The Tobruk splint was especially good for patients with femoral fractures 
and associated abdominal injury. About 30 degrees of knee flexion could be obtained 
in the device. This was useful in distal fractures. Splint was applied while traction was 
being maintained on the femoral fracture. Rubber tubing maintained traction with 
countertraction being maintained by the ischial ring, which was well padded. The pa¬ 
tient’s lower extremity was fixed, ready for evacuation if necessary. 





PENETRATING INJURIES OF THE THIGH 


25 




Figure 7.— An ipsilateral femoral and tibial fracture with a contralateral below-knee am¬ 
putation in continuous skin traction. In such cases, bivalving the cast before evacuation was 
indicated. The cast should end at the top of the iliac crest and not extend onto the chest. A 
spica which is too high limits respiratory exchange which results in decreasing pO : . 




26 


ORTHOPEDIC SURGERY IN VIETNAM 


The decision about which of the two types of immobilization should be used de¬ 
pended on the surgeon's assessment of the adequacy of the debridement and pres¬ 
ence of associated injuries, the flow of patients, and the number of casualties. If the 
patient was not scheduled for immediate evacuation, the modified Tobruk splint with 
a half-ring splint, foot extension, and slings supported the extremity (fig. 6). The pre¬ 
viously placed Steinmann pin and bow were attached distally with surgical tubing to 
the foot extension on the half-ring splint. Dressing or plaster of Paris bandages were 
applied directly over the limb and leg splint for greater immobility. For early evacua¬ 
tion to an offshore hospital or to CONUS, the second type of immobilization, a one 
and one-half spica, was applied without extension onto the chest and without exces¬ 
sive abduction of the legs in order to limit mobility of the fracture during air evacua¬ 
tion. The two portions were held together with plaster bandages (fig. 7). 

If signs of sepsis, excessive drainage, or excessive pain at the fracture site oc¬ 
curred following the initial wound surgery, the patient was returned to the operat¬ 
ing room for reexamination under anesthesia. In the highly compartmentalized 
thigh, more than a single operative procedure was frequently necessary to achieve a 
surgically clean wound, particularly after a combat injury with its associated pene¬ 
trating foreign bodies. 

No attempt was made to perform delayed primary closure of these wounds in 
hospitals in Vietnam because of the relatively high breakdown rate of wounds of 
the thigh treated by delayed primary closure. No closure was preferable to wound 
breakdown following premature closure. These wounds healed better by secondary 
intention or later wound excision and closure. This was true even for those patients 
who could not be evacuated because of associated vascular injuries or wounds to 
the chest or abdomen. 

Vascular injuries which caused interruption in distal blood flow were the most se¬ 
rious trauma an extremity could receive because failure to restore distal blood flow 
quickly would lead to the loss of the limb (Bagg 1967). Treatment began with imme¬ 
diate action to control bleeding, followed by adequate wound debridement. Vascular 
repair to restore blood flow distally had to be accomplished as soon as possible if the 
extremity was to survive. Repair of vascular injuries received priority in the treat¬ 
ment of the injured extremity. In Vietnam, both the equipment and surgical skills 
were available to repair injuries to the femoral artery. The most critical factor in the 
success or failure to reinstitute distal blood flow was the interval of time between the 
injury and the reestablishment of the blood flow. The major cause of failure of the 
vascular repair was low-grade sepsis secondary to poor or no debridement. 

When an arterial injury was associated with a fractured femur, although the or¬ 
thopedic surgeon assisted the vascular surgeon, the primary concern was the rapid 
restoration of distal flow. While adequate wound debridement was absolutely neces¬ 
sary, fracture management could be delayed. Internal fixation was rarely needed and 
indeed was considered contraindicated because of the time required (CINCPACM 
1970). Soft tissue coverage over bone or fracture site at the time of initial surgery 
was not necessary in most injuries of the thigh but, when arterial injury was involved, 
it was necessary to obtain good soft tissue coverage over the vascular repair. 

Patients who sustained a vascular injury and repair were kept in Vietnam for 
three weeks to allow time for the vascular repair to stabilize before the trauma of 
evacuation unless the military situation precluded this course of action. When the 


PENETRATING INJURIES OF THE THIGH 


27 


patient was evacuated, he was encased in a spica cast that was usually bivalved so 
that the site of vascular repair and a point of proximal control of arterial bleeding 
were both readily accessible. 

The military orthopedic surgeon had to keep his priorities in order, especially in 
the combat zone. Reduction and fixation of the fracture, accomplished as expedi¬ 
tiously as possible, were performed only on those occasions when stabilization was 
necessary to avoid further injury to soft tissues or to prevent placing the vascular re¬ 
pair in jeopardy. In these situations, transfixation with Steinmann pins was usually 
satisfactory; intramedullary fixation was rarely the procedure of choice. The reduc¬ 
tion of bone length could be an advantage for the vascular surgeon, but reduction 
and fixation of the femur before vascular repair were usually contraindicated. The 
procedure increased the time between injury and restoration of blood flow, the time 
required for the first surgical exposure, and the time the surgeon was required to de¬ 
vote to the individual patient when numerous casualties were awaiting treatment, 
and, in addition, added to the risk of sepsis. 

After initial surgical treatment, the patients were considered for evacuation. Ad¬ 
equately hydrated patients with stable vital signs and acceptable hematocrits were 
ready for evacuation. Most patients evacuated to offshore hospitals arrived five to 
eight days after injury. If possible, moving the patient in difficulty was delayed until 
his condition was as close to optimal as possible. 

TREATMENT IN JAPAN 

During 1968, 1,658 patients with fractures of the femur passed through the hos¬ 
pitals of the United States Army Medical Command in Japan. From this group, an 
in-depth review of 300 cases provides a picture of the patient from wounding to ul¬ 
timate disposition. 

All of the patients were healthy, young, physically fit men on active duty in Viet¬ 
nam during wartime. The cause of the injury to the thigh ranged from hostile action 
to falls (table 1). Seventy-three percent of the soldiers in the series were in the pay 
grades E-l to E-4, 15 percent were noncommissioned officers, grades E-5 to E-9, 
and 12 percent were commissioned or warrant officers. 

Thirty-one medical facilities in Vietnam sent patients to hospitals in Japan 
where, after several weeks of treatment (average length 18.1 days), they were sent to 
forty-six different CONUS medical centers. The average period of hospitalization 
before return to duty or separation from active duty was 300 days. Seventy percent 
of soldiers with combat-sustained fractures of the femur were not able to return to 
duty and required medical separation. They averaged 418 days of hospitalization 
from time of injury to separation and required nearly one-half million patient days 
of care (1,658 X 300 = 497,400). Thus, in spite of technical improvements, the com¬ 
bat-incurred femoral shaft fracture remained a fracture with significant morbidity, as 
evidenced by the data in this chapter. 

The distribution of the fractures along the shaft of the femur shows a spread of 
39 percent midshaft; 37 percent distal third; 25 percent proximal third, including the 
intertrochanteric area and femoral neck; and 3 percent undetermined (table 2). 


28 


ORTHOPEDIC SURGERY IN VIETNAM 


Table 1 .—Mechanism of injury of300 patients with fractured femurs 


Mechanism 


Number of Patients 


Gunshot wounds: 

Hostile action. 119 

Friendly forces or self-inflicted. 22 


Subtotal. 141 


Fragmentation wounds: 

Land mine and booby trap. 43 

Grenade fragments. 17 

Artillery and mortar fragment. 18 

Not specified. 25 


Subtotal. 103 


Other mechanisms (motor vehicle, aircraft parachute jump, bunker cave-in. 

Howitzer recoil, propeller blade, fall, falling object, concussion). 56 


Subtotal. 56 


Total. 300 


Table 2. — Location and type of femoral fracture 


Region 


Percentage of 

Open Fractures Closed Fractures 


Total 


Hip (femoral neck and intertrochanteric) 

Proximal femur. 

Midshaft.. 

Distal femur. 

Cortex. 

Undetermined site. 


9.3 

1 . 

10.3 

14.7 

1 . 

15.7 

22. 

8.7 

30.7 

28.3 

3.4 

31.7 

9. 

0 

9.0 

— 

— 

2.6 


The 34 percent of patients who incurred fractured femurs secondary to frag¬ 
ment wounds had the highest incidence of associated organ injuries. Ten patients (3 
percent of the survey group) eventually required amputation of the extremity. Six 
of these were done within five days of wounding secondary to failure to restore vas¬ 
cularity of the extremity after a concomitant vascular injury. Three amputations, 
performed while the patients were hospitalized in Japan, were necessitated by non- 
viability of the extremity resulting from vascular injury and massive distal infection. 
One was performed in a CONUS hospital because of residual causalgia, chronic in¬ 
fection, and marginal blood flow. This case was also accompanied by a sciatic nerve 
injury. Twenty-seven cases (9 percent) sustained ipsilateral fractures of the tibia. 

Patients received in Japan from Vietnam with penetrating injuries of the thigh 
had received fairly standard treatment. Surgeons had already debrided the wound, 
removing all nonviable tissue and fascia without debriding the bone. The wound 
had been thoroughly irrigated and appropriate open drainage established. Exposed 
bone was allowed to remain exposed. Surgeons in Vietnam did not do swinging 
muscle or muscle cutaneous flaps over the bone, nor did they repair nerves. 


































PENETRATING INJURIES OF THE THIGH 


29 


Some patients were evacuated to Japan in Tobruk splints, some with modified 
Tobruk splints and the bivalved spica. Transportation in the spica had the potential 
of lowering the patient's p0 2 because this cast limited the patient’s ability to breathe. 
Upward displacement of the diaphragm further compromised the respiratory capac¬ 
ity because expansion of intraviscal gas (resulting from the increase in the plane's al¬ 
titude) distended the abdomen. The adverse effects on the patient, however, proved 
transient. Patients usually arrived in Japan no later than five days after injury. 

During the early war years, variations in treatment occurred from hospital to 
hospital and physician to physician in the Pacific Command. Gradually, a standard 
method of treating fractured femurs emerged. If the patient was fairly comfortable 
and medically stable, he rested for the day following his arrival while baseline val¬ 
ues were established and he was sufficiently rehydrated. Then, with the patient 
under sedation or anesthesia in the operating room, the spica case was removed 
and further debridement, if appropriate, was performed. 

Wound breakdown following delayed primary closure was higher in wounds of 
the thigh than in most other parts of the body. The high incidence of failure for de¬ 
layed primary closure of these penetrating wounds of the thigh associated with frac¬ 
tured femurs can be explained by several factors. The wounding agent created a rel¬ 
atively large cavity, in which necrosis of the tissue occurred. When debridement of 
this and of other devitalized tissue was performed, the debridement created a 
rather large permanent cavity that was often inadequately drained. As a result, the 
policy on the management of these wounds gradually changed until secondary or 
delayed primary closure became the exception rather than the rule. Wounds were 
allowed to heal by secondary intention or by wound excision and closure at a later 
date. In most instances, the patient treated with “no closure" had the extremity 
placed in balanced suspension, preferably with the tibial pin for traction, until the 
wound was healed. Anterior wounds required different procedures because treat¬ 
ment in balanced suspension required leaving the patient in a supine position. 
Drainage by counter incision posteriorly proved ineffective. Debridement created 
dead space and longitudinal traction tended to maintain it. In this case, when the 
dead space could not be obliterated, no closure gave better results than delayed pri¬ 
mary or secondary closure. 

Once the fractured femur was in satisfactory position and “sticky,” a spica cast 
was applied and the patient considered for air evacuation to a CONUS hospital. 
Since the four to six days the patient might be in transit and the up to two stopovers 
enroute, each requiring transfer from the airplane to a medical facility, were ex¬ 
hausting, many factors had to be considered in making the decision to evacuate. In 
particular, medical personnel had to consider the capability of the patient to sustain 
so many days in transit before arrival at his final destination, when only emergency 
medical care could be undertaken en route. 

In the majority of patients reevaluated in CONUS, removal of the travel-spica 
cast revealed no loss in bony alignment. Once reinstituted, balanced suspension suc¬ 
cessfully held the alignment of the femur until union occurred. Soft tissues usually 
healed promptly. In those cases where delayed primary closure had broken down, 
the wounds were allowed to heal by secondary closure after a simple redebridement. 


30 


ORTHOPEDIC SURGERY IN VIETNAM 


TREATMENT IN CONUS—AMBULATION IN THE CAST BRACE 

In the early years of the Vietnam War, the ambulation treatment regimen for 
femoral fractures sustained in combat was similar to methods of treatment during the 
latter part of World War II and the Korean conflict. Use of these techniques, such as 
traction or the ambulatory spica, did not permit physiologic compression of the frac¬ 
ture and ambulation did not occur until internal fixation was present. In the 1960s, a 
new modality, the cast brace, proved to be an effective adjunct when the patient 
reached the ambulatory stage. The cast brace demonstrated that awaiting internal fix¬ 
ation before ambulation was not necessary. This was an important development be¬ 
cause early ambulatory status improved the patient’s well-being, his appetite, and the 
status of his wound. It was not at all unusual to see a febrile patient with a large open 
wound become afebrile and his drainage become thin after a few days of ambulation. 
The cast brace, which allowed upright posture since the wearer was not encumbered 
by a bulky cast, provided a support which invited active muscle activity and easier 
wound drainage (Connally et al. 1973; Moll 1973). The cast brace was the most signif¬ 
icant innovation in treatment of combat-wounded patients with fractures of the 
femur that military medicine developed during the Vietnam era (fig. 8). 

Success with ambulatory management of tibial shaft fractures turned attention to 
the ambulatory management of patients with open comminuted femoral fractures. At 
the urging of Dr. Vert Mooney, Col. Charles Metz at Walter Reed embarked on early 
ambulation of femoral shaft fractures. The concept of early weightbearing ambula¬ 
tion in open comminuted femoral shaft fracture cases (Mooney et al. 1970) appealed 
to all military surgeons. Those experienced in managing open tibial fractures were 



Figure 8. —The cast brace or its variations allowed stabilization of the thigh muscula¬ 
ture, weight-bearing ambulation, active knee motion, and physiologic use of the limb 
musculature. 



PENETRATING INJURIES OF THE THIGH 


31 


certain the method would be successful. The distal one-third of the femur could be 
handled easily because support of the bone could be achieved by controlling the soft 
tissue at and above the fracture site. However, in the proximal injuries, the proximal 
fragment was relatively uncontrolled and the inability to control hip abductor func¬ 
tion ultimately resulted in a varus angulation. Brown (1971) concluded that, although 
application of the cast brace was critical and time-consuming, it offered many advan¬ 
tages. The patient s morale improved, he gained weight, developed better muscula¬ 
ture, and took an interest earlier in rehabilitation. Unfortunately, angulation up to 20 
degrees could be expected in approximately 20 percent of the high femoral fractures 
ambulated in a cast brace before there was bony stability (Brown 1971). 

Of the first fifty comminuted femoral shaft fractures secondary to penetrating 
injuries treated with the cast brace at Fitzsimons General Hospital in Denver, Col¬ 
orado, over 50 percent of the patients regained more than 90 degrees of motion 
(Burkhalter 1973). In a similar series at Valley Forge General Hospital, all forty- 
five patients in the group had over 90 degrees of motion before discharge from the 
hospital. The patients in both series had nonunion of the fractures only where there 
was extensive bone loss (Deffer et al. 1971). 

Bailey et al. (1976) reported a series of 156 patients with open femoral fractures 
treated at Fitzsimons. The patients usually arrived from the combat zone or an off¬ 
shore hospital in a bivalved hip spica with a Steinmann pin in the tibial tubercle. The 
cast was removed and the limb was placed in balanced skeletal traction. After neces¬ 
sary evaluation and interim care, the patient began exercises for the quadriceps. As 
soon as he gained control of the leg, a cast brace was applied. The device consisted of 
a total contact long-leg cast with the knee in full extension. The plaster was shaped 
into a quadrilateral configuration at the base of the leg. Elastic plaster was used to im¬ 
prove the fit around the root of the leg. Roentgenograms were obtained and, if 
needed, wedging was placed in the cast to correct the angulation. Single axis drop¬ 
lock knee hinges were incorporated the next day. Twenty-four hours later, the patient 
began weightbearing ambulation with crutches. The patient performed the pre¬ 
scribed knee exercises from a sitting position. When enough control was achieved, 
the knee joint in the cast was unlocked. Position and condition of the femur were 
reevaluated radiographically each week for four weeks and monthly thereafter. One- 
third of the fractures at union had angulated. Eight had anteroposterior angulation, 5 
valgus and 38 varus angulation. Of the varus angulation, 24 had less than 10 degrees 
and 14 greater than 10 degrees of angulation. In terms of motion, one month after re¬ 
moval of the cast brace, 93 of the 156 patients had greater than 90 degrees of motion 
of the knee, and 18 had between 70 and 90 degrees. Average time to union of the 
femur was 22.4 weeks. Two “nonunions” required bone grafts and then united with 
cast brace ambulation. There were three cases of established osteomyelitis. 

Throughout the military, Moll (1973) probably has the earliest and most exten¬ 
sive experience with cast bracing in these open femoral fractures. Of 184 fractures 
in 178 patients at Brooke Army Medical Center, San Antonio, Texas, only 3 failed 
to unite. Malunion—(union with more than two centimeters of shortening and 
more than 10 degrees of varus or valgus angulation) occuired in 15 cases. 

Because of angulatory problems, Deffer et al. (1971) designed a mini-spica cast 
brace applied after the patient gained muscular control of the injured limb, and with 
the hip abducted and flexed to 30 degrees. Radiographs confirmed the position of the 


32 


ORTHOPEDIC SURGERY IN VIETNAM 


fracture. If the position was not satisfactory, it was altered, as necessary, by wedging. 
Knee joints were incorporated and ambulation was instituted. The ankle was not in¬ 
cluded in the cast. In the initial series of thirty-nine fractures, Deffer et al. (1971) re¬ 
ported that only one ultimately resulted in nonunion. All regained at least 90 degrees 
of motion at the knee joint and none had chronic osteomyelitis. Average time to un¬ 
supported weightbearing was approximately twenty-three weeks (5.7 months). 

LESSONS LEARNED 

Without question, the Vietnam experience showed that the loss of significant 
bone complicated the initial treatment and affected the end results significantly. In 
one study from Brooke Army Medical Center, a report on 60 patients with segmental 
bone loss (Moll and Willhoite 1970), only 4 demonstrated a complete segmental loss 
on the initial roentgenograms following injury. The remaining 56 showed the bone 
loss occurred at the time of initial or subsequent debridement. In all reviewed series 
of Vietnam casualties involving fractures of the femur, the greatest cause for non¬ 
union was a significant loss of bone at the fracture site. This finding suggests that de¬ 
bridement of bone should be avoided and that every effort should be made to pre¬ 
clude the development of large segmental bone losses during surgical debridement. 

In the presence of extensive soft tissue injury, skeletal traction, which for most 
patients lasted three to four weeks, caused early fibrosis of the fracture site. Further¬ 
more, compression of the fragments did not occur with ambulation. When bone loss 
caused a shortening of less than two inches, controlled shortening and attempt at pri¬ 
mary bone union were the most effective course of treatment. 

During World War II, Hampton and Cleveland (Hampton 1957) advocated judi¬ 
cial use of internal fixation. During the Korean conflict, Brav and Jeffress (1953) 
and Carr and Turnipseed (1953) observed that in selective cases internal fixation 
may be not only beneficial towards fracture wound healing but may actually be life¬ 
saving. In Vietnam, fixation of closed fractures was usually an elective procedure. 
However, it was used for open fractures, particularly as a late reconstructive mea¬ 
sure. The advantages of the method were many. By restoring bone and joint archi¬ 
tecture, it minimized the use of incumbering external stabilizing devices. It obliter¬ 
ated dead space, thereby accelerating soft tissue healing. And by minimizing the 
chances for displacement of bone that could injure nerves and vessels critical to the 
restoration of the extremity, it facilitated patient handling during transit. 

With the use of the cast brace for functional treatment of femoral shaft frac¬ 
tures, however, union usually occurred without internal fixation, although all series 
of patients included a few that failed to unite with or without persistent drainage. 
Since Brav and Jeffress (1953), Brav (1957) and Carr and Turnipseed (1953) re¬ 
ported excellent results with intramedullary nailing of the delayed or nonunion 
without wound closure, the procedure seemed promising. In a series of 225 open 
femur fractures at the 106th General Hospital in Japan, intramedullary nailing was 
performed in 5 cases through the open wound without adverse effects. 

In cases of bone loss with a healed wound, internal fixation with bone grafting 
of cortiocancellous grafts was possible if length had been maintained in traction 
(fig. 9). The decision to maintain length or allow controlled shortening had to be 


PENETRATING INJURIES OF THE THIGH 


33 




Figure 9. —This patient had only moderate 
soft tissue injuries with a femoral fracture and 
bone loss. Following multiple debridements, 
length was maintained by skeletal traction 
until the thigh was relatively nonreactive. At 
this time bone grafting with plate and in¬ 
tramedullary rod gave a stable fixation. Union 
occurred without infection. 



34 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 10. —Patient sustained a severe soft tissue injury with bone loss. Injury re¬ 
quired multiple debridements, stabilization in traction, and partial closure with 
meshed split-thickness skin grafts. Pedicle flap was “waltzed” from abdomen to fore¬ 
arm to thigh for better coverage. There was subsequent bone grafting with a plate and 
fibula to maintain length and cancellous bone for union. Drainage persisted until the 
union of fracture and the removal of fibular sequestrae and metal plate. 





PENETRATING INJURIES OF THE THIGH 


35 



made within three to four weeks after the injury. If delayed longer, shortening was 
difficult to avoid, even with ambulation. Although shortening of 2 cm. was easily 
accepted by both patient and physician, even shortening of 4 to 6 cm. was recog¬ 
nized and accepted. The latter was usual in the case of some soft tissue injury or loss 
and in complex wounds where there was difficulty getting wound control. In this sit¬ 
uation, maintaining length by bone grafting was not usually considered feasible 
(Moll and Willhoite 1970) (fig. 10). 

Although the cast brace was ideally suited for the open comminuted femoral 
shaft fracture, angulating malunion occurred in the more proximal fractures. In this 
group of patients, osteotomy with internal fixation was carried out following union 
and rehabilitation of the extremity. 

Wounds with persistent drainage or potential chronic osteomyelitis also concern 
the military physician because they preclude healing. Although antibiotics certainly 
proved an invaluable adjunct, they did not preclude the surgeon’s responsibility for 
distinguishing between local wound contamination, local wound infection, systemic 
infection, or a combination of these conditions. Wound contamination was usually 
contained at the time of debridement with irrigation and excision of tissue, and sys¬ 
temic infections subsided with use of appropriate antibiotics. Localized wound in¬ 
fection usually subsided when union was obtained. 

Except in desperate situations, there appeared to be little need to use internal 
fixation. If debridement, drainage, and antibiotics did not stabilize the wound area 
and the patient, intramedullary nailing of the infected femur was carried out, as ad¬ 
vocated by Brav and Jeffress (1953) following the Korean conflict (Brav 1957). The 
value of the early ambulation following I-M nailing or use of the cast brace cannot 
be overstated in hastening the healing process and reducing the number of cases of 
persistent drainage or osteomyelitis. 


36 


ORTHOPEDIC SURGERY IN VIETNAM 


The orthopedic surgeon had to be constantly aware of the problems that could 
follow a vascular repair. Massive swelling of the calf with the requirement for fas- 
ciotomy had to be considered. Thrombosis was possible any time during the first 
two weeks. Disruption at the site of anastomosis was also possible and was usually 
secondary to infection because of inadequate debridement. The nursing staff 
needed standard operating procedures for action if disruption of arterial repair oc¬ 
curred. All treatment relating to the fractured femur had to be supported by the 
program which gave the best assurance of a successful and lasting vascular repair. 
At all times, the medical personnel needed easy access both to the site of vascular 
repair and to an area of proximal digital control. 

During the course of initial treatment of the fractured femur, previously unde¬ 
tected vascular lesions sometimes surfaced. Palpation of extremities was therefore 
part of the routine examination in the management of combat injuries. Metallic 
fragments near the course of major vessels (identified on roentgenograms) height¬ 
ened the index of suspicion of an unrecognized vascular injury. One patient with a 
fractured femur who should have been in an anabolic course continued in a 
catabolic course with a persistent tachycardia and was suspected of having an un¬ 
recognized arteriovenous fistula. These lesions made themselves known by sponta¬ 
neous hemorrhage from wound sites, an area of rapidly increasing swelling, or by 
palpation of a thrill over a course of a vessel. Such unrecognized vascular lesions 
were fairly common. During the course of treating patients with extremity injuries, 
personnel were cautioned to watch diligently for any evidence of such lesions. 

In some cases, vascular repair was unsuccessful. The inability to restore success¬ 
ful distal circulation usually resulted in ablation of the nonviable portion of the ex¬ 
tremity. When this occurred, primary rules of surgery continued in effect: the ex¬ 
tremity with the fractured femur was ablated at the most distal site possible. 
Presence of a fractured femur did not alter the decision for a below-knee amputa¬ 
tion if the vascular supply to the extremity supported an amputation at that level. 
Consideration was not given to amputation at the fracture site unless there was no 
distal tissue viability. In the majority of cases where below-knee amputation did 
occur, experience has shown that the fracture of the femur healed satisfactorily, and 
the patient could be fitted with a below-knee prosthesis. 

The best concepts and practices from military surgeons of World Wars I and II and 
the Korean conflict were practiced by orthopedic surgeons during the Vietnam War. 
No substitute for adequate debridement was considered. Broad-spectrum antibiotics 
and specific antibiotics for gram-negative and gram-positive organisms were only 
adjuncts to preventing systemic and local infections. Adequate drainage and “no 
closure" were practiced in the care of open wounds involving fractured femurs with 
disruption of surrounding tissues. Reestablishment of distal vascular flow took 
precedence over fracture management. 

Well-done initial wound surgery and early reexploration in signs of sepsis were 
the keys to wound and tracture management. Skeletal traction and exercises to all 
musculature until the patient gained control of the leg followed. The next step was 
weightbearing ambulation with the extremity in a well-fitted cast brace. Early func¬ 
tional rehabilitation gave us superior results. Indeed, the early ambulation of pa¬ 
tients in cast braces appears to be the most outstanding medical innovation of the 
Vietnam conflict for treating thigh wounds. 


PENETRATING INJURIES OF THE THIGH 


37 


REFERENCES 

Bailey, J. D.; Hackthorn, J. C.; Donley, J.; and Burkhalter, W. 1976. Cast brace treat¬ 
ment of femoral fractures. Contemp. Surg. 8:32-36. 

Bagg, R. J. 1967. Presentation before Far East Chapter of Association of Military 
Surgeons. 

Brav, E. 1957. Further evaluation of the use of intramedullary nailing in the treat¬ 
ment of gunshot fractures of the extremities. Journal of Bone and Joint Surgery 
(Am) 39:513-20. 

Brav, E. A., and Fitts, W. T., Jr. 1946. Gunshot fractures of the femoral shaft. Surg. 
Gynecol. Obstet. 82:91-100. 

Brav, E. S., and Jeffress, V. H. 1953. Modified intramedullary nailing in recent gun¬ 
shot fractures of the femoral shaft. Journal of Bone and Joint Surgery 35:141-52. 

Brown, P. 1971. Cast-bracing of fractures sponsored by the National Academy of 
Sciences, Washington, D.C. 

Burkhalter, W. E. 1973. Open injuries of the lower extremity: symposium on 
trauma. Surg. Clin. North Am. 53:1439-57. 

Carr, C. R., and Turnipseed, D. 1953. Experiences with intramedullary fixation of 
compound femoral fractures of war wounds. Journal of Bone and Joint Surgery 
35:153-71. 

CINCPAC^J. 1970. Commander in Chief, Pacific. Fourth CINCPAC Conference 
on War Surgery. Tri-service conference on war surgery conducted in Tokyo, 
Japan, 16-19 February 1970. Incl with Cover ltr, Frank B. Voris, M.D., RADM 
USN, CINCPAC Surgeon, 2 Mar 70. 

Connolly, J. F.; Dehne, E.; and LaFollette, B. 1973. Closed reduction and early cast- 
brace ambulation in the treatment of femoral fractures. Journal of Bone and 
Joint Surgery 55:1581-95. 

Deffer, P. A.; Roschelle, I. A.; and Goodman, F. G. 1971. The management of frac¬ 
tures of the femur by early ambulation utilizing a mini spica cast brace. Pres¬ 
entation at workshop on cast bracing of fractures, sponsored by the National 
Academy of Sciences, Washington. 

DeLorme, T. L.; West, F. E.; and Schriber, W. J. 1950. Influence of progressive resis¬ 
tance exercises of knee function following femoral fractures. Journal of Bone 
and Joint Surgery (Am) 32:910-24. 

Hampton, O. R, Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Oper¬ 
ations. Mather Cleveland, ed. Washington: GPO. 

Moll, J. 1973. The cast-brace walking treatment of open and closed femoral frac¬ 
tures. South. Med. J. 66:345-52. 

Moll, J. J., and Willhoite, D. R. 1970. Abstract: long-bone defects due to missile in¬ 
jury. Journal of Bone and Joint Surgery (Am) 52:835-37. 

Mooney, V.; Nickel, V. L.; Harvey, J. R, Jr.; and Snelson, R. 1970. Cast-brace treat¬ 
ment for fractures of the distal part of the femur. Journal of Bone and Joint 
Surgery (Am) 52:1563. 

Soto-Hall, R. and Horwitz, T. 1946. Treatment of compound fractures of the femur. 
J.A.M.A. 130:128-34. 














3 


Penetrating Wounds of the Leg 
With Associated Fractures of the Tibia 

Colonel William E. Burkhalter, MC, USA (Ret.) 


HISTORICAL BACKGROUND 

During World War I, 4,485 American servicemen incurred fractures of the tibia 
and fibula. Indeed, about 20 percent of all fractures were unstable fractures of the 
lower leg secondary to battle-incurred injury. The morbidity and mortality from this 
injury were significant. In the U.S. Army, for battle-incurred fractures of the tibia 
alone the mortality was 10 percent, and slightly higher if both bones of the leg were 
fractured. The amputation rate in combined injury to tibia and fibula was 906 of the 
4,485 cases or over 20 percent (MD-WW 1927, 493, 499, 507). 

At first, prefabricated splints were used in the management of the injury but this 
method as well as skin or skeletal traction proved unsatisfactory, and both methods re¬ 
sulted in an excessively high rate of nonunion. Tibial fractures made up a substantial 
proportion of battle-incurred fractures, and tibial fracture nonunion was the most 
common nonunion. Surgeons at the time concluded that the nonunions had occurred 
because such fractures required prolonged protection from weightbearing. Thus the 
plaster of Paris cast became the preferred method of treatment (MD-WW 1927, 
507-08,639-41). 

In World War II, military surgeons emphasized the technique of delayed pri¬ 
mary closure in debrided open fractures (Cleveland, ETO 1956; Hampton 1957). In 
the European theater, however, delayed primary closure proved unsatisfactory for 
battle-incurred injuries below the knee and was possible in only 60 percent of the 
cases. In a series of 2,393 delayed primary closures with accompanying fractures, 
primary healing occurred in only 1,592 or about 66 percent. Partial success was 
achieved by the surgeons in 27 percent, but in 6.7 percent of the cases they suffered 
complete failure. In a similar group of wounds allowed to heal by secondary inten¬ 
tion, 87 percent closed in ten to twelve weeks with 5.4 percent incidence of os¬ 
teomyelitis (Cleveland, ETO 1956, 91-99, 151). In the Mediterranean theater. Dr. 
Oscar P. Hampton, Jr., attempted delayed primary internal fixation at the time of 
delayed wound closure in fractures below the knee; but in 41 ol 168 cases, massive 
skin and bone loss occurred (Hampton 1957, 199). 

For battle-incurred fractures of the tibia, treatment continued to emphasize pro¬ 
longed traction and immobilization followed by prolonged nonweightbearing. 
Weightbearing was not permitted until beginning union was demonstrated radio¬ 
graphically. No traction or splints were used to maintain stability (Cleveland and 
Shands 1970, 702). The typical treatment program consisted of a long-leg cast with 


40 


ORTHOPEDIC SURGERY IN VIETNAM 


the knee in various degrees of extension and nonweightbearing. The use of non¬ 
weightbearing ambulation with plaster of Paris immobilization to manage tibial 
fractures continued through the Korean War. 

Delayed primary closure as a technique achieved support from its use in pene¬ 
trating injuries of the thigh and upper extremity. However, delayed primary closure 
with or without internal fixation of the fractures of the lower leg seemed to yield 
relatively poor results. Statistically, this proved to be another fracture in which de¬ 
layed primary closure was not an acceptable technique in early management. 

TREATMENT IN VIETNAM 

In most instances in Vietnam, open injuries below the knee with associated frac¬ 
tures of the tibia were secondary to high-velocity wounding agents, such as mine ex¬ 
plosions and direct bullet wounds, rather than shell fragments. Such wounds were 
compounded from without and contained considerable debris. The company aid- 
man provided initial management of the wound and the fracture. He applied sterile 
occlusive dressing to prevent further contamination from without and to decrease 
bleeding. Tourniquets were not used. Following application of sterile dressings, 
some type of external splintage was needed before evacuation from the field. Al¬ 
though pneumatic splints were sometimes available, the leg was usually placed in 
an Army half-ring splint and held in position with additional slings or triangular 
bandages (fig. 11). Occasionally, bamboo splints and pieces of wood were used. De¬ 
pending upon the area of operation and sophistication of the equipment, intra¬ 
venous fluids and, occasionally, blood were given in the field before helicopter 
evacuation to a fixed facility—a surgical, field, or evacuation hospital. 

Upon arrival at the hospital, the patient went to the triage area where his general 
condition was evaluated and a search was made for additional injuries before surgery. 
Also in triage the patient received intravenous fluids, tetanus prophylaxis, and large 
doses of antibiotics. Although the wound itself was not evaluated at this time, the 
neurocirculatory status of the limb was determined and roentgenograms were ob¬ 
tained in two planes while the limb was supported in the splint. The radiographic ex¬ 
amination, in addition to delineating fracture geography, gave additional information 
about the extent to which the wounding agent had blown gas into the tissues and in 
the tissue planes proximal to the site of injury. The presence of air proximally along 
tissue planes alerted the surgeon that he must explore the area extensively for radi- 
olucent foreign bodies. The occlusive dressing and splints remained in place until the 
patient was in the operating room. Blood transfusions were given as required. 

After initial evaluation, the patient was placed in a preoperative holding area 
and monitored while awaiting surgery. The limb remained splinted with dressings in 
place, and the patient received intravenous fluids or blood and antibiotics. At this 
time, most patients did not require analgesic medication. Splinting the limb seemed 
to decrease post-injury pain. 

In the operating room at least one person assisted the surgeon during the opera¬ 
tive procedure. Treatment began with application of a pneumatic tourniquet and 
prepping the entire extremity. Next, the wound was explored through longitudinal 
incisions with little or no skin debridement. Wide incisions and excisions of fascia 


PENETRATING WOUNDS OF THE LEG 


41 



Figure 11. —In the Republic of Vietnam air splints were available, but sometimes pro¬ 
longed high pressures brought complications such as impending compartment syndromes. 

were performed to allow decompression of individual muscle compartments and 
excellent exposure of neurovascular structures and muscle tendon units. Exposure 
of the arteries and the nerves in the leg during wound debridement allowed protec¬ 
tion of these structures and avoided accidental injury during wound excision. The 
surgeon removed tissue with poor blood supply and poor resistance to infection. In 
addition, with fascial decompression, he exposed individual muscle compartments. 
Release of the fascial envelope from each muscle compartment in the leg permitted 
the muscles to expand freely (fig. 12). 

Before Vietnam, medical opinion held that an open fracture decompressed the 
muscle compartment of the leg and that necrosis of muscle in an intact compartment 
was rare. This belief was not borne out clinically in Vietnam where compartment syn¬ 
dromes were seen in open fractures. However, this condition differed from those re¬ 
ported by Ellis (1958) and by Owen and Tsimboukis (1965) in closed fractures with 
accompanying compartment syndromes* because the combination of an open wound 
with disseminated muscle necrosis throughout the limb resulted in amputation 
(Schmitt and Armstrong 1970). Therefore, fascial decompression was essential be¬ 
cause, without it, muscle swelling in a closed compartment reduced perfusion to the 
muscle and sometimes resulted in ischemic necrosis of an entire compartment. Ide¬ 
ally, fascial release involved all four muscular compartments in the leg to allow maxi- 


*Raymond Bagg, M. D. (Col., MC, USA. Ret.), unpublished records of a longitudinal study of cases 
from 106th General Hospital (1966—1970). William E. Burkhalter, M.D., (Col., MC, USA, Ret.) and D. 
Reich, M.D. Deep posterior compartment syndrome in the lower extremity. 




42 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 12. Evidence of poor debridement. No longitudinal incision for exposure was 
made. Rubber drains will not make up for poor surgery. Patient subsequently became 
a below-knee amputee. 


PENETRATING WOUNDS OF THE LEG 


43 


mum decompression (Kelly and Whitesides 1967). Some vascular injuries in the leg 
resulted in amputation, but usually widespread fascial excision and compartment de¬ 
compression allowed perfusion to improve and the limb to survive. 

The initial treatment was directed primarily to the wound. Exploration and debride¬ 
ment were extremely important at this time; fracture management was secondary. Clo¬ 
sure was not carried out, in any instance, at the time of initial wound surgery. 

At the conclusion of wound debridement, the tourniquet was deflated, a search 
made for major bleeding vessels, and the quality of circulation distal to the site of 
injury evaluated. If no major bleeding points were noted, the tourniquet was rein¬ 
flated, the wound dressed with fine mesh gauze, and a long-leg plaster cast applied 
in two sections. The first section applied was the distal portion with the knee flexed 
at 90 degrees over the edge of the operating table so that gravity would reduce the 
fracture. The second or proximal portion of the cast was applied above the knee, 
after the first part had set and generally with the knee in nearly full extension. 

After the whole cast had hardened, it was bivalved and wrapped with a bandage 
to maintain stability for the fracture and soft tissue injury. Some surgeons in Viet¬ 
nam attempted to use long-leg posterior splints made of plaster of Paris as a substi¬ 
tute for a bivalved long-leg cast, but these repeatedly proved ineffective. The splint 
broke at the knee and at the ankle and did not protect the fracture and soft tissue 
injuries. Also, patients so fitted experienced considerable discomfort during evacu¬ 
ation. Frequently, ill-fitting splints produced pressure sores about the heel and, on 
occasion, a common peroneal nerve paralysis resulted from pressure in the area of 
the fibular head. The stability of the bivalved and wrapped long-leg plaster cast was 
far superior to any type of plaster of Paris splint. 

If signs of sepsis or excessive pain at the fracture site developed during the imme¬ 
diate postoperative period, the patient was returned to the operating room for rede¬ 
bridement and more extensive exploration. In mine injuries or shell fragment 
wounds, particularly, the blast effect frequently carried debris proximally, subcuta¬ 
neously or along fascial planes in the leg. Opening of apparently undamaged muscle 
compartments both proximal and distal to the wound was required. In certain in¬ 
stances, the wounding agent even blew foreign material into the proximal synovial 
tissues, such as the tenosynovium around tendons, or even the joints. If the extent of 
wounding was not appreciated at the time of the initial wound surgery, signs of sepsis 
developed rapidly and the patient became toxic within the first twenty-four hours. 
Reoperation with more extensive proximal longitudinal incisions was then necessary 
to save the extremity. Adequate radiographic films and their perusal at the time of 
the initial injury sometimes helped the surgeon delineate the extent of the problems, 
including gas along tissue planes proximal to the actual wounding site. 

Because of the interest in delayed primary closure in the management of soft tis¬ 
sue wounds as well as wounds associated with fracture, some attempts were made in 
evacuation hospitals in Vietnam to apply this technique. In the early years of the 
Vietnam War, if patients could not be evacuated out of country because of associ¬ 
ated injuries, surgeons attempted delayed primary wound closure after the patient 
was hospitalized in Vietnam for five or six days. Experience showed that this tech¬ 
nique was not effective for penetrating injuries of the leg with associated tibial and 
fibular fractures. This mirrored the World War II experience reported by Hampton 
(1957, 53-57, 160-80). Soft tissues were markedly swollen, frequently skin was lost, 


44 


ORTHOPEDIC SURGERY IN VIETNAM 


and usually the wound was anterior or anteromedial in the leg. If tension is applied 
to the skin of this particular area, known for its poor tolerance of tension, necrosis 
promptly results. Attempts to make relaxing incisions in the posterior calf and to 
shift skin anteriorly were unsuccessful. Associated complications included massive 
loss of skin, subcutaneous infection beneath the transferred skin, and further loss of 
tissue at the fracture site. As a result of this experience early in the Vietnam conflict, 
participants at the first Pacific Conference on War Surgery in 1967 recommended 
against tension closures or skin shifts to cover exposed bone (CINCPAC-1 1967, 40) 
and discouraged relaxing incisions and local rotation flaps. Our experience indicated 
that, even if a patient could not be evacuated because of associated injuries, no at¬ 
tempt should be made to use the technique of delayed primary closure in penetrat¬ 
ing injuries of the leg with associated tibial fractures. Therefore, after the wound had 
been rendered surgically clean in the operating room, the wound was left open and 
an occlusive dressing and plaster cast were applied. If nothing suggested sepsis at the 
fracture site, there was no reason to examine the wound again in Vietnam, even if 
evacuation had to be delayed because of associated injuries. 

Following bivalving of the cast, if the patient was nontoxic, well hydrated, and 
had an adequate hematocrit, and if other injuries permitted, he was evacuated. A 
brief operative note concerning the status of damaged tissues in the limb was sup¬ 
posed to accompany the patient, but this was sometimes lost. In order to assure 
communication in the event that records did not accompany the patient, a conscien¬ 
tious surgeon made notes on the plaster cast regarding whether there were vascular 
or nerve injuries. If there was a nerve injury, the note regarding loss of substance, 
simple contusion, or loss of an entire muscle tendon unit was extremely important 
to the surgeon receiving the patient. Even if operative notes accompanied the pa¬ 
tient, they were usually grossly inadequate; the vital positive and important infor¬ 
mation was not provided on a consistent basis. 

TREATMENT AFTER VIETNAM 

Once the patient left Vietnam, weightbearing ambulation became the goal. In 
1961, Ernst Dehne et al. reported on the management of the tibial shaft fracture by 
weightbearing ambulation in a long-leg plaster cast. This functional method of 
treatment ignored the wound after the initial surgery and concentrated on early 
restoration of function using the long-leg cast. Wound closure occurred by sec¬ 
ondary intention healing under the cast during weightbearing activity. Until 1965, 
this method of management was widely practiced in U.S. Army station and general 
hospitals. Although there was some concern among members of the general ortho¬ 
pedic community about shortening during weightbearing ambulation, the high inci¬ 
dence of union in a relatively short time without associated joint stiffness of the 
foot, knee, or ankle impressed them. The combat-incurred tibial shaft fracture met 
the criteria tor this Junctional method of treatment. The highly comminuted frac¬ 
ture was allowed to shorten in a controlled fashion to improve contact stability. 
Maintenance of lull length by traction invited delayed union or nonunion (Dehne 
et al. 1961a; Dehne et al. 1961b) (fig. 13). 


PENETRATING WOUNDS OF THE LEG 


45 



Figure 13.—In treating tibial shaft fractures, the emphasis was on function. Initially, 
weight-bearing ambulation in a long-leg cast was instituted. Subsequently immobiliza¬ 
tion decreased to a Delbet cast in this case. 


Secondary intention wound healing obviated the need for relaxing incision, ten¬ 
sion closure, covering bone by split-thickness skin grafts, cross-leg flap with its asso¬ 
ciated requirement for internal fixation, and above all the prolonged recumbency 
of the patient. Because of these advantages, the majority of patients with combat- 
incurred tibial shaft fractures were treated by weightbearing ambulation in a long- 
leg plaster cast (Brown 1973; Brown 1974; Dehne 1969; Dehne 1974). 

In certain instances, surgeons covered large wounds of the calf or lateral leg 
with split thickness skin grafts before the beginning of weightbearing ambulation. 
Closure of these wounds decreased fluid loss from the wound and permitted the 
long-leg cast to be kept in position for a longer time without severe odors develop¬ 
ing and cast changes becoming necessary. 

Generally, when a patient with an isolated tibial shaft fracture arrived at a fixed 
facility, he was evaluated in an orthopedic holding area. If there were no signs of sep¬ 
sis and nothing to suggest problems with the wound, a surgeon in mask and gloves 
inspected the wounds. He applied a new sterile dressing and a well contoured, total- 
contact long-leg cast that included a walker. Then the patient was ready for weight¬ 
bearing ambulation. On the other hand, if there were signs of sepsis or considerable 
foul odor and pain in the extremity, the patient was not evaluated in the holding 
area. He was removed instead to the operating theater for further operative expo¬ 
sure, debridement, and exploration. Even in an offshore hospital, such as Tripler 
Army Medical Center in Hawaii and the hospitals in Japan, most of the tibial shaft 
fractures were treated for a few days with weightbearing ambulation using crutches 






46 


ORTHOPEDIC SURGERY IN VIETNAM 


before evacuation to the continental United States. This approach was generally ap¬ 
plicable only to those patients who had an isolated injury below the knee. 

Sarmiento (1967) described his experience with the total-contact short-leg cast 
in the management of tibial fractures. Depending upon the fracture level and the 
severity of the soft tissue injury, this cast was also used after several days, several 
weeks, or several months. The ideal was to increase the range of knee motion and 
muscular activity during weightbearing ambulation. However, in both the short-leg 
cast of Sarmiento and the long-leg cast of Dehne, the goal was to return the dam¬ 
aged lower extremity to full functional activity as rapidly as possible. 

The exposure of tibial cortex and the tibial fracture site was seen frequently in 
penetrating injuries because of the destruction of overlying skin and soft tissues, es¬ 
pecially in the anterior or anteromedial area. Initially, surgeons believed that cover¬ 
ing exposed bone by tissue shifts was necessary to preserve bony integrity and to 
prevent desiccation of the underlying bone. In some large wounds, tissue loss was so 
great that cross-leg flaps for coverage of the bone were thought to be required. How¬ 
ever, in well debrided wounds with an exposed tibial fracture site, union of the frac¬ 
ture occurred without covering the fracture site by tissue shifts, either locally or from 
a distance. The exposed bone was covered by granulation tissue from viable muscle 
peripherally and from VolkmamVs canals in the tibial shaft itself. In the exposed 
bone without periosteum a portion of the tibial cortex may have become necrotic, 
but the actual depth of necrosis was difficult to evaluate, and the management of the 
exposed bone was initially nonsurgical. As secondary intention wound healing pro¬ 
ceeded and the fracture was treated functionally by weightbearing ambulation, the 
obviously necrotic bone tended to separate from viable bone beneath and made the 
decision on depth of bone debridement quite easy. Union of these fractures occurred 
in a similar time frame to that for open fractures and with no greater infection rate. 
Union occurred through the well vascularized posterior and lateral tibial cortex and 
periosteum (Burkhalter and Protzman 1975) (fig. 14). 

In Brown and Urban s (1969) discussion of early weightbearing ambulation of tib¬ 
ial shaft fractures, the authors stated that in a series of 60 adult patients with 63 open 
fractures of the tibia, all fractures united. Forty-two of these 60 patients had combat- 
incurred injuries. In this series, the wounds of 4 patients continued to drain intermit¬ 
tently until the patients were discharged from military service. In these 4 cases, how¬ 
ever, drainage was minimal and did not interfere with normal function of the limb or 
activities of daily living. The final outcome of the drainage was not known. Witschi 
and Omer (1970) discussed their results with 84 patients with tibial shaft fractures in¬ 
curred in Vietnam combat. They reported that after their initial attempts to obtain 
wound closure by split-thickness skin grafts through windows in a plaster cast, their 
concern with soft tissue wound healing gradually abated. They preferred long-leg or 
short-leg casts and ambulatory treatment of the fracture, avoiding excessive concern 
with soft tissue healing. In their series of 84 patients, 7 had established osteomyelitis. 

Burkhalter and Protzman (1975) evaluated 228 combat-incurred open tibial 
shaft fractures treated by debridement, weightbearing ambulation in a long-leg 
cast, and wound healing by secondary intention. They believed that a well debrided 
wound allowed to heal by secondary intention responded similarly to a civilian-in¬ 
curred injury. An open fracture allowed to heal with exposed bone at the fracture 
site required an average of only two weeks additional time before removal of the 


PENETRATING WOUNDS OF THE LEG 


47 


external immobilization than did an uncomplicated open fracture. The infection 
rate in these 228 plus 61 civilian cases was 3.8 percent. All of the these infections oc¬ 
curred in military open-penetrating injuries. 

In a series of 200 tibial fractures that were treated at the 106th General Hospital 
in Japan and were followed by record in two hospitals in the United States (Bagg 
1966-70), thirteen extremities required some type of amputation, either before or 
after arrival at the 106th or in a follow-up hospital. The most common cause for 
these amputations was failure to control sepsis. This was previously reported by 
Schmitt and Armstrong (1970) from the U.S. Air Force Hospital. Clark Air Base, in 
the Philippines, tor the period 1965 through 1967. Ten of the amputations in the 
106th General Hospital series were below the knee and three were above the knee 
or disarticulations of the knee. Five of the patients were lost to follow-up before a 
definitive decision was made regarding function of the leg and union of the bone. 

In bone loss injuries the intent was either to obtain union of the tibia by poste¬ 
rior gratt or to create a posterior tibial fibular synostosis by the position of the graft 
in the interosseous space between the tibia and the fibula. 

Gaines and Reid (1976) from Brooke Army Medical Center in Texas reported 
on 44 infected nonunions of the tibia treated by posterolateral bone grafting. 
Twenty-three of these patients had established osteomyelitis at the time of opera¬ 
tion but were free of drainage. Twelve wounds were actively draining anteriorly at 
the time of the surgery. Following insertion of the graft, the operative wounds were 
allowed to heal by secondary intention, and weightbearing ambulation was started 
within a few days of surgery. Union occurred in all cases and drainage ceased in 9 of 
12 that were actively draining at the time of surgery. 

From Letterman Army Medical Center in San Francisco, Freeland and Mutz 
(1976) described a similar series of 23 infected nonunions treated by posterolateral 
bone grafting. At the time of their operations 12 patients had actively draining 
wounds. Of these 23 cases, all patients achieved bony union. Wounds that were ac¬ 
tively draining in 10 other patients at the time of surgery ceased drainage following 
the operation and union. As in earlier series (Hanson and Eppright 1966; Harmon 
1945; Jones and Barnett 1955), these surgical wounds, created when the posterolat¬ 
eral bone graft was applied, were allowed to heal by secondary intention, and weight¬ 
bearing ambulation in a long-leg cast was started within a few days postoperatively. 

In certain cases of open injury of the leg, large gaps were left in the tibial shaft, 
with or without an intact fibula. Nevertheless, although high degrees of comminu¬ 
tion frequently accompany high-energy missile injuries, loss of bone substance was 
usually minimal. Moll and Willhoite (1970) commented that, while the wounding 
agent might cause actual bone loss, the usual cause for bone loss was overdebride¬ 
ment of the bone at the time of the initial surgery. To avoid these large gaps, sur¬ 
geons should place continuing emphasis on saving all bone, even without attached 
soft tissue. Even though necrotic, these fragments add some immediate support and 
act as a scaffolding for future bone formation. If sepsis becomes a problem, these 
loose pieces of bone can be sequestered, as dictated by the host. 

When large bone gaps were encountered, management of the wound varied with 
the state of soft tissue injury. Wound management of the patient with normal nerve 
and vessel function in the foot, a good functional calf, and good posterior skin dif¬ 
fered considerably from that of a patient with a stiff anesthetic foot and poor muscu- 



48 


ORTHOPEDIC SURGERY IN VIETNAM 





PENETRATING WOUNDS OF THE LEG 


49 




Figure 14. —An open fracture with exposed bone and contralateral above-knee ampu¬ 
tation. Within one year, wound closure and fracture union were accomplished with 
weight-bearing ambulation. 





50 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 15.—A middle one-third tibia bone loss 
problem was managed by multiple debride¬ 
ments. Subsequently a fibular shaft with inter¬ 
nal fixation, supplemented with additional 
bone, gave a healed fracture without infection. 




PENETRATING WOUNDS OF THE LEG 


51 


















52 


ORTHOPEDIC SURGERY IN VIETNAM 


lature in the leg. If the patient's foot and soft tissue in the leg were in reasonably 
good condition so that amputation was initially ruled out, the problem could be ap¬ 
proached in two ways. The most obvious approach was controlled shortening. If 
shortening of two inches allowed bone contact, this was certainly preferable to main¬ 
taining full length and creating a bone loss nonunion. Certainly with only marginal 
soft tissues in the leg, this was proper procedure. Since most surgeons would not ac¬ 
cept more than two inches of shortening, for a loss greater than this, some type of 
bone grafting was necessary. Huntington's fibular shift (Huntington 1905; Wilson 
1941), although adding additional instability by fibular section, was used, in some 
cases, to manage the problem of the tibial shaft loss with the intact fibula (fig. 15). 
This fibular shift was augmented by additional cortical cancellous iliac graft and 
served as one approach to the management of the loss of tibial shaft. The creation of 
a proximal and distal tibial fibular synostosis by using cortical cancellous graft was 
also effective. Both of these procedures avoided poor skin and scar anteriorly, 
placed the bone graft in the best vascular bed (that is, the well vascularized posterior 
calf muscles), and allowed continuing functional activity. The persistence of anterior 
drainage was no deterrent to these posterolateral procedures. 

RECOMMENDATIONS 

The penetrating injury to the leg with associated tibial fracture should be man¬ 
aged by wound exploration and debridement, as indicated. Wound closure by tissue 
shifts or transfer from a distance is generally not required even though there may 
be actual soft tissue loss at the fracture site. Secondary intention wound healing will 
occur beneath a functional plaster cast. The single most important factor in the 
management of the open tibial fracture is early, adequate wound debridement, fol¬ 
lowed by the return of leg function through weightbearing ambulation in a plaster 
cast. Exposure of bone or fracture site is no indication to alter the treatment plan. 
Nonunion with or without infection can be managed successfully in almost all cases 
by posterolateral bone grafting. Union in these cases frequently may bring about 
cessation of drainage from the fracture site. The most widely used method of man¬ 
agement of the open tibial fracture in the Vietnam War consisted of meticulous 
wound debridement and wound exploration, the application of a functional plaster 
cast as soon as possible, and the institution of weightbearing ambulation, also as 
soon as possible. These wounds were allowed to heal by secondary intention. The 
precepts of closed plaster treatment followed in the Vietnam War were those advo¬ 
cated by Trueta (1976) before and during World War II. 

REFERENCES 

Brown, R W. 1973. The open fracture. Clin. Ortliop. 96:254-65. 

-. 1974. The early weightbearing treatment of tibial shaft fractures. 105:167-78. 

Brown, P.W., and Urban, J. G. 1969. Early weightbearing treatment of open frac¬ 
tures of the tibia. Journal of Bone and Joint Surgery (Am) 51:59-75. 

Burkhalter, W. E., and Protzman, R. 1975. The tibial shaft fracture. J. Trauma 

15:785-94. 



PENETRATING WOUNDS OF THE LEG 


53 


CINCPAC-1. 1967. Commander in Chief, Pacific. First CINCPAC Conference on 
War Surgery. Tri-service conference conducted at John Hay Air Base, Baguio, 
the Philippines, 20-25 May 1967. 

Cleveland, M., ed. 1956. Orthopedic surgery in the European Theater of Operations. 
Office of the Surgeon General, Department of the Army. Washington: GPO. 

Cleveland and Shands, A. R., eds. 1986. Orthopedic surgery in the Zone of Interior. 
Office of the Surgeon General. Department of the Army. Washington: GPO. 

Dehne, E. 1969. Treatment of fractures of the tibial shaft. Clin. Orthop. 66:159-73. 

-. 1974. Ambulatory treatment of the fractured tibia. Clin. Orthop. 105:192-201. 

Dehne, E.; Deffer, P. A.; Hall, R. M.; Brown, P. W.; and Johnson, E. V. 1961a. The 
natural history of the fractured tibia. Surg. Clin. (N Am) 41:1495-513. 

Dehne, E.; Metz, C. W.; Deffer, P.A.; and Hall, R. M. 1961b. Non-operative treat¬ 
ment of the fractured tibia by immediate weightbearing. J. Trauma 1:514-35. 

Ellis, H. 1958. Disabilities after tibial shaft fractures. Journal of Bone and Joint 
Surgery (Br) 40:190-97. 

Freeland, A. E., and Mutz, S. B. 1976. Posterior bone-grafting for infected ununited 
fracture of the tibia. Journal of Bone and Joint Surgery (Am) 58:653-57. 

Gaines, J. H., and Reid, R. L. 1976. Salvage of the infected tibial non-union. Jour¬ 
nal of Bone and Joint Surgery (Am) 58:723. 

Hanson, L. W., and Eppright, R. H. 1966. Posterior bone-grafting of the tibia for 
non-union. Journal of Bone and Joint Surgery (Am) 48:27-43. 

Hampton, O. P. Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Oper¬ 
ations. Mather Cleveland, ed. Office of The Surgeon General, Department of 
the Army. Washington: GPO. 

Harmon, P. H. 1945. A simplified surgical approach to the posterior tibia for bone-graft¬ 
ing and fibular transference. Journal of Bone and Joint Surgery (Am) 27:496-98. 

Huntington, T. W. 1905. Case of bone transference: use of a segment of fibula to 
supply a defect in the tibia. Ann. Surg. 41:249-51. 

Jones, K. G., and Barnett, H. C. 1955. Cancellous-bone grafting for non-union of 
the tibia through the posterolateral approach. Journal of Bone and Joint Sur¬ 
gery (Am) 37:1250-60. 

Kelly, R. P, and Whitesides, T. E., Jr. 1967. Transfibular route for fasciotomy of the 
leg. Journal of Bone and Joint Surgery (Am) 49: 1022-23. 

MD-WW. 1927. The Medical Department of the United States Army in the world 
war. vol. 11, pt. 1. Washington: GPO. 

Moll, J. H., and Willhoite, D. R. 1970. Long-bone defects due to missile injury. Jour¬ 
nal of Bone and Joint Surgery (Am) 52:835-36. 

Owen, R„ and Tsimboukis, B. 1965. Incidence of ischaemic contracture following 
closed injuries to the calf. Journal of Bone and Joint Surgery (Br) 47:184. 

Sarmiento, A. 1967. A functional below-the-knee cast for tibial fractures. Journal of 
Bone and Joint Surgery (Am) 49:855-75. 

Schmitt, H. J., Jr., and Armstrong, R. G. 1970. Wounds causing loss of limb. Surg. 
Gynecol. Obstet. 130:682-84. 

Trueta, J. 1976. Reflections on the past and present treatment of war wounds and 
fractures. Military Medicine 141:255-58. 

Wilson, P. D. 1941. A simple method of two-stage transplantation of the fibula for 
use in cases of complicated and congenital pseudarthrosis of the tibia. Journal of 
Bone and Joint Surgery (Am) 23:639-75. 

Witschi, T. H., and Omer, G. E„ Jr. 1970. The treatment of open tibial shaft frac¬ 
tures from Vietnam war. J. Trauma 10:105-11. 



























































































4 


Wounds of the Hand 

Colonel William E. Burkhalter, MC, USA (Ret.) 

The hand wound is unique in military surgery. The wound is not mortally danger¬ 
ous, but without meticulous care, it can be the source of considerable disability for 
years. Because hand wounds are not life threatening, the priority for evacuation and 
early surgery is low. In the patient with multiple injuries, a hand wound is treated 
after lifesaving surgery has been performed, the normal procedure in both military 
and civilian hospitals. About 15 percent of combat-incurred injuries have a hand in¬ 
jury alone or associated with injuries to other limbs, the abdomen, or the chest (Bun¬ 
nell 1955, 20). Despite the relative benignity of the wound, injury to the hand, wrist, 
or distal forearm is of considerable interest to military surgeons because a soldier is 
militarily useless without use of his hands. Thus, these lightly wounded personnel may 
be the source of great loss of manpower and utilize many military medical resources. 

DEVELOPMENT OF ARMY HAND SURGERY* 

Wounds of the hand have been a common problem for the military surgeon for 
some time. Maj. Gen. George E. Armstrong, former Surgeon General of the Army, 
pointed out that in the Civil War (1861-65) hand wounds numbered approximately 
one-ninth of wounds recorded in the Union Army (Bunnell 1955, v). Approxi¬ 
mately 15,200 flesh wounds of the hand and 12,865 fractures of the hand and wrist 
bones caused by shot injury were recorded. Despite this high incidence, hand 
wounds received little special attention. In the official Medical and Surgical History 
of the War of the Rebellion (MSHWR 1876), only six pages are devoted to hand 
wounds and operations and an additional twenty-four pages to wrist wounds and 
operations, a pattern that continued in World War I. In the volume published in 
1927 that describes the Medical Department of the U.S. Army in World War I, 
fewer than 500 lines cover the subject of hand injuries (MD-WW 1927). 

By World War II, however, with the increasing specialization of American 
medicine, some surgeons began to concentrate on wounds of the hand, which com¬ 
prised a substantial portion of all wounds. One estimate indicates that of the 
592,170 persons wounded and injured in action during World War II, 148,042 (25 
percent) incurred upper extremity wounds and 88,825 (15 percent) had wounds or 
injuries which affected the hand. Some 22,000 injured hands were treated in hospi¬ 
tals in the Zone of Interior (Bunnell 1955, 17-75). 

One surgeon particularly interested in hand wounds was Dr. Sterling Bunnell. 
In November 1944, Bunnell began the first of a series of eight tours of the nine 


*Raymond M. Curtis. M.D., contributed to this section. 



56 


ORTHOPEDIC SURGERY IN VIETNAM 


hand centers in the Zone of Interior. In the fall of 1945, despite the fact that the 
centers were at the peak of their activity and surgeons assigned to them were oper¬ 
ating on 933 patients a month, he found the centers had few hand surgeons (Bun¬ 
nell 1945). Nonetheless, out of these hand centers came the impetus for the devel¬ 
opment of this important specialty of surgery. 

Dr. Bunnell's visits allowed him to put surgeons interested in hand surgery in con¬ 
tact with each other. In the fall of 1945, Drs. S. Benjamin Fowler, Robert Payne, Dar¬ 
rel T. Shaw, and George Van O. Webster met in the quarters of Dr. Joseph H. Boyes 
at the Newton D. Baker General Hospital to discuss the formation of a hand group. 
On 20 January 1946, the American Society for Surgery of the Hand was organized in 
Chicago, with thirty-five founding members present (Curtis 1971; Reid 1979). 

After World War II, when residency training programs in orthopedics and plas¬ 
tic surgery were established, the need to include training in hand surgery was ap¬ 
parent. The outbreak of the Korean War once again demonstrated the need for 
hand surgeons, but the Army found hand specialists in short supply. Only a few 
Regular Army officers had been assigned to the hand centers during World War II, 
and the last of the centers, Letterman Army General Hospital in San Francisco, had 
discharged its last hand patient in 1948. The solution was to appoint civilians, many 
of whom had served during World War II in the hand centers, as consultants to the 
general hospitals. One particular center of hand work was Valley Forge General 
Hospital, Pennsylvania, where Dr. J. William Littler, who had been a surgeon in a 
hand center during World War II, acted as civilian consultant, assisting Capt. Erie 
E. Peacock, Jr., MC. Despite the obvious need for hand specialists, a hand service 
was not organized at Walter Reed General Hospital until 1960, when Col. John D. 
Blair, MC, then chief of orthopedics at Walter Reed, assigned Lt. Col. Charles W. 
Metz, Jr., assistant chief of orthopedics, the duty of establishing a hand service and 
a one-year fellowship in hand surgery. To assist in the organization of this program. 
The Surgeon General, Lt. Gen. Leonard D. Heaton, appointed Dr. Raymond M. 
Curtis Consultant in Hand Surgery to The Surgeon General on 31 May 1960. 

Although the hand service at Walter Reed was a part of the orthopedic service, this 
special year of training was open to any Army medical officer. The orthopedic service 
was staffed so that one officer, after completing his fellowship, remained as the assis¬ 
tant chief of orthopedics and the chief of the hand service, thus providing continuity 
within the hand service and the supervision and teaching needed for each new fellow. 

The program was organized to make it possible to train enough officers with 
special interest and expertise in hand surgery to assign one to each general hospital. 
By 1963 this was possible, and when the casualties from Vietnam began to arrive, 
specialists in hand surgery were available at each general hospital to manage these 
difficult problems. By 1979, thirty-six Army Medical Corps officers had completed 
the fellowship in hand surgery at Walter Reed (Reid 1979). 

General Management of Hand Wounds 

As a rule, hand wounds in the Republic of Vietnam were initially managed by a 
fully or partially trained orthopedic surgeon with an interest in hand surgery, who, if he 
had no formal training in hand surgery, was supervised or assisted by a surgeon with 
special interest or training. Initial wound management began in the triage area with 


WOUNDS OF THE HAND 


57 




Figure 16.— A blast injury to hand with skin and bone loss. Initial wound debridement 
was followed by reexploration in four days. Redebridement was required, followed by 
arthrodesis of interphalangeal joint of long finger and wound closure. Function was in¬ 
stituted seven days after injury. 




58 


ORTHOPEDIC SURGERY IN VIETNAM 





WOUNDS OFTHE HAND 


59 









60 


ORTHOPEDIC SURGERY IN VIETNAM 


examination of the hand and forearm for nerve, vascular, or tendon injury and the ap¬ 
plication of a simple wound dressing. At this time, because the low priority for hand 
surgery led to delays in operating on these wounds, the hand was elevated and splinted 
to minimize swelling. Usually penicillin and tetanus prophylaxis were administered. A 
radiographic examination of the hand at this time was extremely important so that 
fractures, foreign bodies, and dislocations could be diagnosed prior to surgery. Most 
injuries of the distal portion of the upper extremity had tendon, bone, and joint in¬ 
volvement, as well as associated dislocations. Basilar joint of the thumb and inter- 
carpal or carpometacarpal dislocations occurred from the penetrating injury or from 
the fall following the wounding. In the triage area, roentgenograms done in two planes 
to determine the extent of bone and joint injury frequently disclosed large metallic 
fragments, such as pieces of shell casing and spent bullets, lodged in the tissues. 

In the operating room, the wound was examined with a pneumatic tourniquet in 
place for temporary hemostasis, adequate light, and either general or axillary block 
anesthesia. Initially, the surgeon focused on the meticulous cleaning of the skin and 
fingernails to reduce foreign body and bacteria contamination. After satisfactory 
preparation, the wound was explored. The majority of hand wounds required exten¬ 
sion into physiological incisions for exposure of damaged structures and for the pro¬ 
tection of undamaged structures during wound debridement. Additional incisions 
for exposure included opening the carpal tunnel to protect the median nerve and its 
branches during debridement of proximal palmar injuries. In crushing wounds, in¬ 
trinsic muscle decompression was performed through small dorsal longitudinal inci¬ 
sions. These incisions extended into the intermetacarpal spaces and decompressed 
these closed spaces between the metacarpal shafts. The status of injured structures 
was noted in the operative records, and surgical extensions were described. 

Leaving the wound open after the initial debridement allowed the surgeon to reex¬ 
amine the tissues in three to seven days (fig. 16). At that time, viable and nonviable 
muscle could be distinguished more easily, and decisions about future management 
could be made. Debridement of intrinsic muscle resulted in considerable loss of func¬ 
tion and was avoided, if possible, during staged wound management. However, this did 
not imply that the initial exploration and debridement were unimportant. If the initial 
surgery failed to clean the wound thoroughly, the second procedure would inevitably 
involve debridement of a wound that would probably become infected. Therefore, ini¬ 
tial surgery guidelines called for minimal skin debridement and generous fascial exci¬ 
sion. Bone, tendons, nerves, and blood vessels were preserved, and only nonviable 
muscle was excised. Questionable tissue was left to await a second-look procedure. Al¬ 
though Bunnell, in World War II, had maintained that hand wounds should be closed 
immediately after wound debridement, in Vietnam, highly contaminated hand wounds 
were not closed at the time of the initial wound surgery but were managed like other 
wounds. This procedure proved best in literally hundreds of cases (Burkhalter et al. 
1968; Butler 1969; Jabaley and Peterson 1973; Churchill 1944; Cutler 1945). 

After complete wound exploration and debridement, as indicated, the hand was 
rendered surgically clean in the operating room. The wound was then dressed with 
tine mesh gauze and an occlusive dressing that offered gentle compression by fluffs 
placed between individual fingers, helped avoid swelling, supported the wounded 
parts, and positioned the thumb in opposition to avoid stiffness in a nonfunctional 
position. A plaster splint stabilized the wrist. A piece of stockinette, triangular ban- 


WOUNDS OF THE HAND 


61 




Figure 17._This patient had previous index ray excision for injury to index finger. The 

patient sustained a through-and-through high-velocity wound of the hand treated by 
debridement, followed in six days by stabilization with spacer wires and wound closure. 
Within nine days after injury, function was instituted. Motion at twelve days after injury. 




62 


ORTHOPEDIC SURGERY IN VIETNAM 





WOUNDS OF THE HAND 


63 



dage, or muslin was fashioned into a sling to maintain elevation with the elbow sup¬ 
ported and without constriction. Elevation was unremitting either in the sling while 
asleep or by the use of the patient’s own musculature. 

After initial surgery, the patient with a hand injury was ready for evacuation ei¬ 
ther to an evacuation hospital in the Republic of Vietnam or to an offshore hospi¬ 
tal. His evacuation priority was based on medical preference, the tactical situation, 
and his associated injuries. Ideally, no matter where he was sent, the occlusive 
dressing was maintained in place for three to seven days. The patient was then 
placed under anesthesia in an operating room for a second wound exploration. In 
this procedure, the surgeon at an evacuation or offshore hospital, rather than the 
original surgeon, searched for nonviable muscle, loose bone, necrotic fascia, and 
foreign bodies. When the wound was free of necrotic tissue and foreign debris 
through debridement and inspection, the surgeon planned the reconstruction. The 
first consideration was skeletal stability. With minimal degrees of comminution, in¬ 
ternal fixation of fractures with a small Kirschner wire gave the stability necessary 
for early action motion. Dislocation, in addition to fracture, sometimes gave insta¬ 
bility to the hand. The two most commonly noted and frequently missed disloca¬ 
tions were at the basilar thumb joint and the carpometacarpal joint, either of the 
two ulnar-most digits or all the carpometacarpal joints of the hand. The severe soft 
tissue wound plus the dynamics of the dislocation made internal fixation with 
Kirschner wires almost mandatory after reduction of the dislocation. Loss of reduc¬ 
tion during subsequent operative procedures or during evacuation was sometimes 
associated with considerable morbidity and functional loss. 

If bone loss was present or comminution was extensive, spacer wires applied to 
the metacarpals could be used to maintain metacarpal length and give stability. 


64 


ORTHOPEDIC SURGERY IN VIETNAM 


These spacer wires were created by the operating surgeon at the operating table. 
Proximally the wire was placed in the medullary canal of the proximal portion of 
the metacarpal fracture and bent at 90 degrees at the fracture or bone loss site so 
that the wire then abutted on the cortex. Another 90 degree bend was made back to 
the original plane of the wire. These two 90 degree bends allowed cortical abut¬ 
ment. The bone loss length system dictated the next 90 degree bend in the wire dis- 
tally at the area of cortical bone and then another 90 degrees so that it went in the 
medullary canal of the bone distally. If this was in the cancellous head, longitudinal 
traction on the finger could bring about increase in length and then the wire could 
be snapped into position. Generally, two or more of these 0.045 inch Kirschner 
wires crossed obliquely could be used to maintain length, and additional wires in¬ 
creased necessary stability. Although the term “spacer wire” has been used, the 
major usefulness of these devices lay in achieving skeletal stability so that even in a 
bone loss situation active motion could be instituted (fig. 17). 

Although there was a temptation to perform tendon and nerve repairs in a wound 
that was clean and ready for closure, the explosive injury with widespread multitissue 
damage throughout the hand did not lend itself to this type of surgery. Further trauma 
and immobilization were not needed in the hand with such widespread damage. Thus, 
at the secondary operative procedure, tendon and nerve repair was not generally car¬ 
ried out. The emphasis was placed on achieving a surgically clean wound that would 
accept closure without the development of infection but with stable skeletal structures. 

Finger and thumb amputations or partial hand loss generally occurred at the 
time of wounding. The initial wound surgeon, therefore, performed only initial 
wound exploration and debridement of a traumatic amputation rather than ampu¬ 
tation surgery. Unfortunately, at the initial surgery, there was a tendency to remove 
nonfunctional but viable tissue. Obviously, in the hand with multiple injuries, all vi¬ 
able tissue should be preserved. Fingers that are useless but have skeletal structures 
supporting usable tissues should be maintained at the initial wound surgery. Re¬ 
moval of skeletal stability at the time of the initial wound surgery results in loss of 
skin support and, if for any reason wound closure could not be carried out on 
schedule, the skin would shrink and lose its usefulness as a covering agent. At the 
time of the second look, finger filleting could be done and wound closure achieved 
with skin that had been under normal tension just a few minutes before. 

Wound closure is an elective operative procedure that should be carried out 
when the wound is free of necrotic tissue and foreign bodies and has a low bacterial 
count. Clinically, in most situations, the surgeon carrying out wound closures at the 
second look determined the absence of necrotic tissue and foreign bodies by inspec¬ 
tion because lack of resources generally prohibited bacterial counts. Methods of 
closure usually used were direct suture, split-thickness skin graft, or finger fillet. If 
skin loss was a problem, split-thickness skin graft, with or without meshing, was car¬ 
ried out. Surgeons avoided local tissue shifts within the hand, volarly or dorsally, 
because infection and poor blood supply might result in loss of transposed tissue. 
Wound closure failures occurred in the hand, as in other parts of the body, because 
of dead space, lack of drainage, or closure under tension. Delayed primary closure 
of hand wounds was successful in 95 to 98 percent of the cases (fig. 18). 

Certain explosive wounds required pedicle tissue from a distance for wound clo¬ 
sure. If so, following the initial wound surgery, the patient should have been evacuated 


WOUNDS OF THE HAND 


65 




Figure 18.—Multiple open fractures with skin loss. Five days after debridement, inter¬ 
nal fixation of the fractures was accomplished. The wounds were closed by split-thick¬ 
ness skin grafts. Peritenon covering the extensor tendons supported the revasculariza¬ 
tion of the split-thickness skin graft. 




66 


ORTHOPEDIC SURGERY IN VIETNAM 












WOUNDS OF THE HAND 


67 



immediately to a fixed facility with considerable holding capability where the proce¬ 
dure could be carried out under ideal circumstances. In those cases where this was not 
done and abdominal pedicle flaps were applied in Vietnam at the time of the initial 
surgery or at the time of the second look, difficult problems occurred postoperatively 
for the patient, the physician, and the hospital staff. Because of time lost during evacu¬ 
ation and lack of good management during the evacuation process, patients leaving 
Vietnam with abdominal pedicle flaps in place usually arrived at their destinations 
with low grade wound infections, edematous stiff hands, considerable discomfort in 
the shoulder and elbow, displaced dressings, and flaps frequently lost because of dis¬ 
placed dressings or tension (Butler 1969). If the patient required pedicle flap coverage, 
the procedure should have been carried out in a delayed primary fashion that would 
have allowed evacuation of the patient to an offshore or a more permanent facility and 
permitted a second look before wound closure. Then, after surgeons removed necrotic 
tissue and foreign bodies, the flap could be applied. Ideally, the flap was applied to an 
optimally debrided wound. Because of the requirement for secondary surgery, flap 
coverage as the method of closure at delayed primary time usually was indicated for 
dorsal skin and tendon loss, with or without fracture. Thumb web space and palmar 
skin loss areas accepted split-thickness skin graft closures readily. 

Reconstructive Surgery 

Reconstructive surgery of the combat-incurred hand injury was done at an off¬ 
shore hospital or in the United States. The decision to evacuate a patient who still had 
his hand in the initial wound dressing was based on patient flow, volume of cases, and 
lack of associated injuries that precluded early evacuation. Some patients arrived in 



68 


ORTHOPEDIC SURGERY IN VIETNAM 


continental United States (CONUS), often within two weeks of injury, with their 
open hand wounds in the dressings applied at the time of initial wound surgery. 
Within CONUS, these patients then underwent all reparative surgery, such as reduc¬ 
tion and stabilization of fractures or fracture dislocations and closing of wounds. 

The timing of reconstruction in the patient with a penetrating hand injury was im¬ 
portant. Achieving a closed wound with minimal tissue reaction and with a stable 
skeleton meant that rehabilitation could be instituted. Active motion, splintage to im¬ 
prove overall range of motion, and the use of the hand in activities of daily living and 
light work were all used in the rehabilitation effort. Between wound closure and re¬ 
constructive surgery, the aims included achievement of a full range of active motion, 
passive motion, or both; absence of swelling; and giving the patient the ability to use 
whatever hand function he had in some useful endeavor. Full range of motion meant 
no contractures, but in this group of combat-injured hand patients, achievement of a 
full range of even passive motion was unlikely. Some residual deformity would likely 
remain, but the absence of swelling and the hands usefulness and relative freedom 
from pain generally indicated readiness for reconstructive procedures. Even today, 
regardless of the type of reconstruction contemplated, the criteria indicated above 
should be met before undertaking a reconstruction operative procedure. Results of 
premature operative procedures, performed too close to the time of the initial 
wounding and when the hand is still reactive, often failed, discouraging both patient 
and physician. Waiting too long was preferable to operating prematurely. 

Reconstructive surgery for the patient with a complex hand injury with skin loss 
usually took place at an offshore hospital where wound exploration or skin closure 
was done. The most obvious methods of wound closure for explosive injuries, were 
finger fillet or split-thickness skin graft. Postoperative management of the split¬ 
thickness skin graft of the hand usually consisted of applying an occlusive dressing 
for four to six days with subsequent dressing changes. However, the irregular 
wound surfaces, perhaps with postoperative bleeding or oozing, frequently compro¬ 
mised the overall “take” rate. Because of the limited success of the split-thickness 
graft, the hand was frequently immobilized for many days. The open technique, 
which had been so successful in the grafting of lower extremity wounds (the graft 
could be observed frequently and rolled back to keep fluid from collecting beneath 
it), did not lend itself readily to hand wounds because of the gross irregularity of the 
surfaces and the need for early joint motion. 

To cover burns. Tanner, Vandeput, and Olleg (1964) described the technique of 
creating mesh out of split-thickness skin grafts by placing parallel cuts to increase 
the graft size. The Tanner-Vandeput method of meshing autogenous skin graft 
proved well suited in dealing with extensive skin loss on the lower extremity. Mesh¬ 
ing increased the graft size. The high “take” rates characteristic of this technique 
seemed to be related to its inherent drainage characteristics, its tendency to con¬ 
form well to the irregular surface, and its rapid adherence to the recipient site. For 
the same reasons, this approach promised to be just as satisfactory for coverage of 
open hand wounds as for similar injuries in the lower extremity. Experience proved 
that the ability of the graft to conform to the irregular and cavitary type of hand 
wound plus the drainage characteristic made this an excellent method of obtaining 
wound closure in a complex explosive injury. Moreover, the rapid adherence of the 
graft to the recipient shortened immobility time following grafting. 


WOUNDS OF THE HAND 


69 


Shaffers experience (1971) with mesh skin graft in the hand demonstrated an 
average “take rate of 93 percent. He believed that at least 50 percent of these pa¬ 
tients did not require a further operative procedure, either for cosmetic or func¬ 
tional requirements. That is, the graft was satisfactory and did not have to be re¬ 
placed by pedicle tissue. Mesh grafts adhered more quickly than sheet grafts. The 
decreased period of immobility to achieve wound closure prevented loss of motion 
in severely damaged hands that had complex disseminated injuries. Once its advan¬ 
tages became clear, the meshed split-thickness skin graft was widely used to achieve 
rapid wound closure in offshore and CONUS hospitals. 

Secondary intention wound healing as a method of skin closure proved effec¬ 
tive, contrary to the belief of many authorities that allowing hand wounds to heal 
by secondary intention brought about stiffness and loss of motion. If skin loss was 
considerable and if the hand was immobile or splinted in a poor position, this was 
indeed true. If the patient, however, was capable of actively moving the joints and 
tendons, stiffness did not result, regardless of the status of the skin cover. Certainly 
this was seen in the patient with dorsal burns who achieved full mobility before au¬ 
togenous skin grafting. Active motion within a few days of injury was the key to 
prevention of motion loss and joint stiffness, and it was much easier to prevent this 
condition than to overcome it, once established, surgically or by splintage. In cer¬ 
tain instances in which tendon or bone work was necessary to overcome fixed de¬ 
formities, pedicle flap coverage from a distance became necessary. For years, the 
classic abdominal pedicle flap or thoracoabdominal flap to give fat and full-thick¬ 
ness skin had been the standard of reconstruction for these damaged hands. In 
1917, Aymard described a deltopectoral flap based on the perforating vessels of the 
internal mammary artery. This flap was used for nasal reconstruction. At about the 
time of the outbreak of the Vietnam War, Bakamjian (1965) promoted a similar flap 
for pharyngeal and esophageal reconstruction. McGregor and Jackson (1970) men¬ 
tioned the use of this deltopectoral flap in hand surgery. They pointed out that the 
flap could be elevated without delay, tubed to produce a closed system, and rotated 
almost 180 degrees upon itself. The flap could be made long enough to allow skin 
coverage on either the palmar or the dorsal surface of the hand or wrist. In addi¬ 
tion, the location of the flap in the deltopectoral area permitted elevation of the 
hand during transfer of the flap (fig. 19). The tube pedicle provided enough free¬ 
dom for active use of the fingers and wrist during transfer of the skin. The large 
donor defect in the chest and arm was the only real deterrent to its routine use. 
Stein and Morgan (1972) presented their experience at Valley Forge General Hos¬ 
pital with the deltopectoral flap for the release of contractures, for resurfacing 
areas of skin loss both volarly and dorsally, and as an effective aid in osteoplastic re¬ 
construction of the thumb. The general belief of many hand surgeons in CONUS 
was that the deltopectoral flap was extremely usable in the hand. They were in 
agreement with McGregor and Jackson (1970), who believed that the deltopectoral 
flap was a marked functional improvement over the abdominal pedicle because of 
the quality of skin, the creation of the tube system without delay, and the persistent 
elevation of the hand during skin transfer. 

Reconstructive surgery could also involve bone grafting, which was frequently neces¬ 
sary after penetrating hand trauma. Extreme degrees of comminution and bone loss sec¬ 
ondary to injury, debridement, or both usually required the addition of bone to achieve 


70 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 19.—A viable but unstable index finger following a blast injury with bilateral 
above-knee amputations. An abdominal flap was used for coverage and arthrodesis of 
all joints of the index finger in the thumb position which gave excellent function. 




WOUNDS OF THE HAND 


71 








72 


ORTHOPEDIC SURGERY IN VIETNAM 


union. These bone grafts were most frequently used in the metacarpals and were only 
rarely necessary in the phalanges. Spacer wires in the metacarpals of the fingers gave suf¬ 
ficient stability to the digits so that active motion and external splintage, if necessary, 
could be instituted. Once these wires were in place, there was no immediate requirement 
to bone graft the metacarpal to prevent shortening. In single metacarpal injuries of the 
long or ring finger, bone loss did not usually require spacers because of splintage by the 
metacarpals on adjacent sides. The deep intermetacarpal ligaments gave stability and 
prevented shortening to a significant degree. In this situation, the severity of the soft tis¬ 
sue injury and the ability to maintain or achieve motion in the digit determined whether 
bone grafting or ray amputation was the appropriate reconstructive surgery. The iliac 
crest was the most widely used donor site for bone grafts in the hand. 

Multiple operative procedures in the severe open injury that required insertion of 
a bone graft and internal fixation of the graft certainly set the stage for development 
of infection because cortical bone tolerates sepsis poorly and rarely is revascularized 
in the presence of infection. The osseous tissue obtained from the iliac crest for bone 
grafts in the hand could be both cortical and cancellous for rapid union and revascu¬ 
larization. The graft could then be either tri- or bicortical, depending on whether both 
inner and outer table and the crest were removed. The graft could be fashioned easily 
to fit any deformity. Internal fixation with Kirschner wires generally gave adequate 
stability so that early motion could be instituted. This graft would be incorporated 
even in the presence of sepsis. Generally, cortical cancellous iliac grafts needed only 
short periods of protection before instituting full use of the extremity (fig. 20). Patho¬ 
logic fractures of the graft, as might be encountered in cortical bone, were not seen. 

When bone grafting to replace bone loss, if the length of bone had not been 
maintained during the interim by adjacent metacarpals, by traction, or by various 
types of spacer wires, no attempt was made to regain length during the reconstruc¬ 
tive operative procedure. Attempted lengthening following weeks or months of 
shortening resulted in marked tightening of the intrinsic muscle tendon unit with 
subsequent difficulty in finger flexion and subluxation or dislocation of the 
metacarpophalangeal joint. 


Tendon Injury 

One has only to read the hand surgery volume of the Medical Department, 
United States Army, Surgery in World War II series (Bunnell 1955) to realize the 
serious problem posed by the flexor tendon injury from 1942 to 1946. The combina¬ 
tion of multiple tissue injuries, generally one or more fractures, sometimes low- 
grade sepsis, and often delay between injury and surgery compromised the overall 
result in this group of patients. The wide dissemination of injury delayed tissue 
equilibrium, frequently for many months. The association of tendon injury, scar tis¬ 
sue with or without fracture, and nerve injury militated against achieving a good 
functional result from free graft or transfer. 

During the Vietnam conflict, two approaches were used to restore tendon func¬ 
tion. One, basically, was the complete debridement of all scar tissue, including pulley 
tendon remnants, along the course of the bed to be grafted. Skin with the fat was then 
applied to the underlying bones and joints. At this time, joint releases or nerve grafts 
could be achieved. Frequently this excision of tendons and their remnants resulted in 


WOUNDS OFTHE HAND 


73 



Figure 20.—This patient incurred bone loss injury to first metacarpal with resultant 
adduction contracture of the thumb. In addition to the adduction contracture, note the 
supination deformity. Note the amount of tissue loss when the thumb is properly posi¬ 
tioned. Bone graft in place with thumb position by K-wires in maximum abduction. 
Coverage of the defect by a tailored abdominal flap extending into the palmar surface 
of the hand. The raw surface of the carrier is covered with split-thickness graft. The ul¬ 
timate function is good, but bulk is excessive. 




74 


ORTHOPEDIC SURGERY IN VIETNAM 







WOUNDS OF THE HAND 


75 








76 


ORTHOPEDIC SURGERY IN VIETNAM 



a rather marked increase in the passive range of motion of the digit. When the finger 
was believed to be unreactive and ready for a further operative procedure, a tendon 
graft operation was carried out without pulleys. Rather than open all portions of the 
previous incision, the tendon in these areas was actually burrowed into the subcuta¬ 
neous space without creating formal pulleys. Three to four weeks after the tendon 
graft, motion was instituted. The aim was to use either removable rings or the pa¬ 
tient s finger on the opposite hand to act as temporary pulleys until motion within the 
digit was achieved. After finger motion through the graft was achieved, pulley recon¬ 
struction or wearing of a ring for a prolonged period of time could be prescribed. The 
results were variable, and the process took many months. Usually three operative 
procedures were required to achieve a functional digit (Butler et al. 1968). 

Another approach, as reported by Hunter (1965), required Silastic implants and 
the creation of artificial tendon sheaths. These implants were used in complex in¬ 
juries that had both a poor tendon bed and poor tendon substance. Considerable 
difficulty was initially encountered with the implant because of foreign body reac¬ 
tion, infection, and the development of synovitis. However, surgeons were eventu¬ 
ally able to use the artificial tendon extensively to create a better bed for tendon 
grafting in severely damaged hands. The artificial tendon was placed in the poor 
tendon bed, joint releases were carried out as indicated, and nerve repairs or grafts 
done at the same time, if indicated. Three to six months after the insertion of the ar¬ 
tificial tendon and achievement of a functional range of passive motion, a tendon 
graft was pulled into the artificial sheath and anchored proximally and distally. This 
gave more predictable results than the scar excision technique and was used by 
many surgeons in Army hospitals throughout the United States. 



WOUNDS OF THE HAND 


77 


The Wrist 

The wrist is the key to hand function because a mobile painless wrist is required 
for normal hand function. Penetrating injuries of the carpus and the distal radius 
created highly localized problems that compromised hand function even in the ab¬ 
sence of significant tendon or nerve injury. The penetrating injury in this area of 
eight carpal bones damaged considerable articular surface and this, coupled with 
ligament injury and bone loss, often brought about intercarpal subluxations and 
dislocations. In addition, because of the proximity of bone and tendon and of bone 
and nerve in this area, foreign bodies and bone fragments were sometimes dis¬ 
placed into the carpal tunnel, where they caused secondary compression of the me¬ 
dian nerve or interference with flexor tendon gliding. 

In Vietnam, the initial management of the penetrating injury of the wrist was 
similar to that of other hand injuries. However, in the wrist area, anatomic exposure 
was extremely important. Considerable carpal injury could be created by even a 
small fragment with small entrance and exit wounds. Exploration of this limited 
area through the wounds of entrance and exit was difficult. Consequently, with 
carpal injuries, a physiological volar exposure generally was carried out. This expo¬ 
sure brought about release of the carpal tunnel, protection of the median nerve 
during debridement, and also permitted wound exploration as indicated. After de¬ 
bridement, some type of external immobilization was usually imposed to prevent 
the volar flexed position of the wrist. The wound itself was managed as were other 
hand wounds, preferably with delayed primary closure. 

Prolonged splintage of these fractures with the wrist in slight dorsiflexion or at 
least avoiding volar flexion was usually the method of management. This method 
allowed the osseous injury in the wrist to consolidate and permitted emphasis to be 
placed on movement of flexor and extensor tendons with full mobility of fingers 
and thumb. If required, elastic traction was applied to aid in both flexion and exten¬ 
sion of the fingers. In the early years of the Vietnam War, immobilization for these 
injuries was believed to be only a matter of a few weeks. Later it became obvious 
that the longer the immobilization, the more stable the wrist would be, and the in¬ 
creased stability would permit the patient heavy use of the wrist and fingers with lit¬ 
tle discomfort. In certain cases of extreme articular damage with bone loss, sur¬ 
geons attempted to use Silastic implants in the wrist joint. However, the irregular 
bone loss gave poor Silastic support and made the maintenance of a mobile and 
painfree wrist difficult, even with good motor control. The generally excessive in¬ 
stability in the wrist then resulted in poor distal finger function. 

It soon became clear that arthrodesis of the wrist was a far superior method of 
management for the severe open distal radius and carpal injury. But the bone loss 
problem made arthrodesis of the wrist difficult in certain instances. The use of late 
internal fixation in the form of a compression plate, with or without additional bone 
graft, allowed minimal external immobilization. With this internal stability, addi¬ 
tional procedures could be carried out at the time of wrist arthrodesis (fig. 21). 
Tenolysis of the extensor tendons with metacarpophalangeal joint release could be 
carried out easily at the same time, without concern for loss of stability of the 
arthrodesis. Postoperatively, traction loops to bring about metacarpophalangeal 
flexion could be added without particular difficulty. The arthrodesis with oi without 


78 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 21.—Severe explosive injury to the wrist with bone, tendon, and skin loss. Fol¬ 
lowing multiple debridements, closure was accomplished by an abdominal flap. 
Arthrodesis of the wrist with creation of a one-bone forearm by centralization of hand 
over ulna. Stability was achieved by a large plate and screws. With a stable base for func¬ 
tion, tendon grafts to the extensor tendons beneath the flap gave this functional result. 



WOUNDS OF THE HAND 


79 










80 


ORTHOPEDIC SURGERY IN VIETNAM 



the compression plate was the most frequently employed method of management 
for the significant penetrating injury to the carpus or distal radius. 

CONCLUSIONS 

Inasmuch as orthopedic residency training requires at least some exposure to 
hand surgery, a surgeon with an interest and training in surgery of the hand was 
usually available in Vietnam to treat the patient with a hand injury. Guidelines from 
other surgeons emphasized the initial management of the wounded hand, the im¬ 
portance of debridement without primary closure of the wound, and early (three to 
seven days) evacuation to a facility for definitive management. 

In offshore hospitals, where physicians with interest and training in hand surgery 
also managed the hand-injured patients, the second operative procedure was carried 
out. At this point, achieving skeletal stability was most important. With skeletal sta¬ 
bility achieved with Kirschner wires or spacer wires, motion of joints and tendons 
could be instituted. After the patient's second procedure, an occupational therapist 
helped him to improve active hand motion with exercise and splintage. 

Upon arrival in CONUS, the patient was usually sent to a specialized treatment 
center for reconstructive hand surgery. These centers, established in designated 
general hospitals to improve the overall management of those patients, were 
staffed by orthotists, occupational therapists, and usually graduates of the hand fel¬ 
lowship program at Walter Reed General Hospital. All in all, wounded soldiers 
with hand injuries received excellent care throughout the treatment chain, from the 
point of initial wounding to the large military medical center. 



WOUNDS OFTHE HAND 


81 


REFERENCES 

Aymard, J. L. 1917. Nasal reconstruction. Lancet 2:888-91. 

Bakamjian, V. Y. 1965. A two-stage method for pharyngoesophageal reconstruction 
with a primary pectoral skin flap. Plast. Reconstruct. Surg. 36:173-84. 

Bunnell, S. 1945. Suggestions to improve the early treatment of hand injuries. Bull. 
U.S. Army Med. Dept. 88:78-82. 

Burkhalter, W. E.; Butler, B.; Metz, W.; and Omer, G. 1968. Experiences with de¬ 
layed primary closure of war wounds of the hand in Vietnam. J. Bone Joint Surg. 
(Am) 50:945-54. 

Butler, B., Jr. 1969. Initial management of hand wounds. Milit. Med. 134:1-7. 

Butler, B., Jr.; Burkhalter, W. E.; and Cranston, J. P. III. 1968. Flexor-tendon grafts 
in the severely scarred digit. J. Bone Joint Surg. (Am) 50:452-57. 

Churchill, E. D. 1944. The surgical management of the wounded in the Mediter¬ 
ranean theater at the time of the fall of Rome. Ann. Surg. 120:268-83. 

Curtis, R. M. 1971. Surgery of the hand, its past, present, and future. J. Bone Joint 
Surg. (Am) 53:810-12. 

Cutler, C. W., Jr. 1945. Early management of wounds of the hand. Bull. U.S. Army 
Med. Dept. 85:92-98. 

Hand surgery. Surgery in World War II. See MD-HS. 

Hunter, J. M. 1965. Artificial tendons—their early development and applications. J. 
Bone Joint. Surg. (Am) 47:631-32. 

Jabaley, M., and Peterson, H. Early treatment of war wounds of the hand and fore¬ 
arm in Vietnam. Ann. Surg. 177:163, 1973. 

McGregor, I. A., and Jackson, I. T. 1970. The extended role of the delto-pectoral 
flap. Br. J. Plast. Surg. 23:173-85. 

MD-HS—Medical Department, U.S. Army. 1955. Hand surgery. Surgery in World 
War II. Washington: GPO. 

MD-WW—Medical Department, U.S. Army. 1927. The Medical Department of the 
United States Army in the world war , vol. II, pt. 1. Washington: GPO. 

The medical and surgical history of the War of the Rebellion. See MSHWR. 

The Medical Department of the United States in the world war. See MD-WW. 

MSHWR—U.S. Surgeon Generals Office. 1876. The medical and surgical history of 
the War of the Rebellion , vol. 2, pt. 2. Washington: GPO. 

Reid, R. L. 1979. Hand surgery and the military: A historical review. Milit. Med. 
144:385-88. 

Tanner, J. C., Jr.; Vandeput, J.; and Olley, J. F. 1964. The mesh skin graft. Plast. Re¬ 
construct. Surg. 34:287-92. 











5 


Wounds of the Foot 

Colonel Anthony Ballard, MC, USA (Ret.) 

While foot disease and injuries were rarely life threatening during the Vietnam 
conflict, they did result in prolonged morbidity and great loss of manpower. A con¬ 
siderable amount of this morbidity can be attributed to inadequate treatment of 
what appeared to be minor wounds. Many minor foot wounds were ignored by the 
soldier until a deep infection had become well established and the function of the 
foot seriously compromised. Medical facilities tended to compound the problem by 
giving foot wounds the lowest priority and providing treatment that frequently in¬ 
cluded inadequate debridement. 

The majority of orthopedic surgeons serving in the Republic of Vietnam during 
the early years of the conflict were not trained to carry out the extensive explo¬ 
ration and debridement of the foot necessitated by many of the wounds. Because of 
a general unfamiliarity with the plantar compartments of the foot and fear of plan¬ 
tar incisions, attempts at wound debridement were frequently carried out through 
medial, lateral, or dorsal, rather than plantar approaches. However, these tech¬ 
niques were inadequate for complete debridement. Moreover they placed the ten¬ 
dons and neurovascular structures of the plantar aspects of the foot in jeopardy.* 

TREATMENT PRINCIPLES 

Preoperative clinical and radiographic assessment of the foot to determine the 
extent of damage to the nerves, vessels, and bony architecture was the first step in 
treatment. Anteroposterior, lateral, and oblique roentgenograms of the foot and 
ankle were taken to evaluate the extent of damage to the bones and joints. If the in¬ 
jury was secondary to a fall from a height or to explosive forces directly beneath the 
foot, fractures of the femoral neck of lumbar vertebrae were suspected and roent¬ 
genograms also were made to evaluate these areas. 

The extent of damage to the nerves of the foot was determined by checking the 
pinprick sensation of the areas supplied by the major nerves. Anesthesia over the 
medial plantar surface of the foot indicated damage to the medial plantar nerve, 
while altered sensation over the lateral one-fourth of the sole and fourth and fifth 
toes indicated lateral plantar nerve damage. Anesthesia of the heel pad was sec¬ 
ondary to injury to the calcaneal branch of the posterior tibial nerve. 

Assessment of vascular injury was critical. Surgeons in Vietnam recognized that 
the foot was supplied with blood through extensive anastomosis of the dorsalis 
pedis, posterior tibial, and peroneal arteries. Although interruption of any of these 


♦Unless otherwise indicated, anatomical discussions in this chapter are based on Anatomy of the 
human body (Gray 1959). 



84 


ORTHOPEDIC SURGERY IN VIETNAM 


vessels usually would not jeopardize the survival of the foot, injuries that caused ex¬ 
tensive swelling within the deep compartments of the foot could compromise the 
blood supply through all three vessels, resulting in reduced vascularity and either 
loss of the foot or deep extensive fibrosis (Omer and Pomerantz 1972). In particu¬ 
lar, hindfoot dislocations, crush injuries, and injuries resulting from explosions di¬ 
rectly beneath the foot were more likely to cause extensive vascular damage and 
compromise more than were gunshot wounds (fig. 22). 



Figure 22.— Necrosis of the forefoot 
due to unrelieved swelling following 
crush injury of the foot. 


Analysis of vascular injury was made primarily by clinical evaluation of skin 
color, temperature, and palpable pulses. In some centers, ultrasonic flow detectors, 
angiography, and plethysmography supplemented clinical evaluation of circulation 
(Lavenson, Rich and Strandness 1971; Strandness and Bell 1965; Rusher et al. 
1967). The ultrasonic flow detector could determine arterial flow through the digi¬ 
tal arteries of the toes even in a grossly swollen foot. 

The procedure for foot debridement was designed to remove contaminants and 
necrotic tissue as well as to open the deep compartments to release pressure and thus 
preserve viability of the tissues. Viability of muscle was determined by its color, con¬ 
tractility, capillary bleeding, and consistency (CINCPAC-3 1969, 15-19). Of these 
four viability determinants, muscle consistency was the most reliable. A necrotic mus¬ 
cle rapidly lost its firm rubbery consistency and had a mushy feeling when grasped 
with forceps. This finding was usually present at the time of initial debridement. 

Neither muscle contractility nor muscle color were reliable signs of viability. If 
the debridement was carried out under tourniquet hemostasis, after several pinches 




WOUNDS OFTHE FOOT 


85 


with the forceps, the muscles would no longer contract and could be mistaken for 
tissue no longer viable. At the time of initial debridement, muscle color was also 
not a reliable indicator of viability because muscle tissue damaged either directly or 
indirectly by the passage of a missile was altered by diffuse blood about the fibers. 
Although this gave the muscle an unhealthy hue, in many instances the majority of 
the muscle fibers retained their viability. 

Wherever possible, lacerated common and proper digital nerves were debrided 
of contaminants and the free proximal ends were left buried deep in the foot sur¬ 
rounded by soft tissue. Repair of the nerves was not attempted during the initial de¬ 
bridement. Loss of function of the medial plantar nerve rendered three-fourths of 
the plantar surface of the foot anesthetic and, in some instances, badly compro¬ 
mised foot use. If skin closure over the medial plantar nerve was feasible, it was re¬ 
paired proximal to its branching. After debridement of contaminants and necrotic 
tendon tissue, lacerated tendons were left unrepaired. 

Since the foot could survive evacuation if either the dorsalis pedis or posterior 
tibial artery remained patent, except in a few instances, vascular repair distal to the 
midcalf was not attempted in the war zone. However, if both vessels were disrupted, 
they were ligated and viability of the foot was determined at a later date. (Laven- 
son, Rich and Strandness 1971). Amputation subsequently became necessary in 
some cases because of avascularity of the remaining part. In some of the CONUS 
medical centers, microvascular repair of vessels was done, but even when operating 
microscopes, fine nonabsorbable sutures, and a well-trained surgical team were all 
available, patency of the vessel was difficult to maintain. 

Surgeons treated the damaged skeleton of the foot by removing all small, con¬ 
taminated, and isolated bone fragments, leaving those larger fragments still at¬ 
tached to soft tissue in place to serve as subsequent bone grafts. This procedure was 
especially important in the first metatarsal region. Internal fixation of bones to 
maintain alignment was not performed during the initial debridement. In appropri¬ 
ate cases, it could be performed at subsequent operative procedures when the 
wound was determined to be clean (CINCPAC-3 1969, 68). 

Following the surgical removal of contaminated and necrotic tissue, wounds 
were thoroughly flushed with saline or an antibiotic solution. This was done by 
placing the tip of the irrigating device into the depth of the wound and, with gentle 
pressure of the fluid, floating loose debris to the surface. In some treatment facili¬ 
ties in Vietnam, attempts were made to cleanse the wound with a dental instrument 
that produced pulsating jets of water under pressure. This method was controver¬ 
sial. Its advocates contended that this was an effective method of removing superfi¬ 
cial contaminants from tissue while others believed that this resulted in further 
imbedding or spreading of the contaminants throughout the wound area. Although 
the pulsating water method was not widely used in the treatment of foot wounds in 
Vietnam, further experience has demonstrated the efficacy of pulsating lavage. 

After debridement, wounds were left open and dressed with fine mesh gauze 
over the raw surfaces. The lower leg and foot were encased in bulky dressings. 
Drains proved to be ineffective and were discouraged (CINCPAC-3 1969, 15-19). 
Splints were applied from the knee to beyond the tips of the toes to stabilize the un¬ 
derlying fractures and injured soft tissues. All wounds were inspected live to seven 
days after debridement. If depths of the foot had been entered by either the wound- 


86 


ORTHOPEDIC SURGERY IN VIETNAM 


ing device or the surgeon, this second look was done in the operating room with ap¬ 
propriate anesthesia, tourniquet hemostasis, adequate lighting, and surgical instru¬ 
ments. The entire wound was reexplored and any remaining necrotic tissue excised. 
Only if the wound was clinically clean did surgeons perform necessary internal fixa¬ 
tion of fracture, nerve repair, and closure. 

The foot was immobilized and elevated for ten to fourteen days after injury. 
Crutch ambulation was started when the edema had begun to subside. Weightbear¬ 
ing (utilizing patellar tendon-bearing casts to reduce the amount of weight borne by 
the plantar surface of the foot) was dictated by the extent and type of fractures. 
After skeletal stability had been achieved, weightbearing was helpful in reducing 
the morbidity resulting from the extensive disuse osteoporosis. 

Primary closure of war wounds of the foot should rarely be considered (Omer 
and Pomerantz 1972). Delayed primary closure at five to seven days allowed re¬ 
assessment of debridement and its adequacy without a significant delay in healing 
and was generally safer than primary closure. Even then, delayed primary closure 
was done only if the sound edges of the wound could be brought together and su¬ 
tured without tension. Relaxing incisions or undermining edges of the skin to close 
the wound was not recommended because they resulted in a high rate of wound 
breakdown and increased skin loss. Delayed primary closure was usually applicable 
only to wounds of the dorsum of the foot and was not recommended for plantar 
wounds, since wounds on the plantar surface or sides of the foot without large areas 
of skin loss closed readily by secondary intention (Omer and Pomerantz 1972). 

The skin over the ball of the foot was frequently associated with damage to the 
adjacent toes. When this occurred, the toes were filleted and the skin was used to 
cover the weightbearing area of the distal forefoot. This skin retained its sensibility 
and held up well with continued use. Incidence of deep infection of these wounds 
was lower with this approach than it was with delayed closure. 

When feasible, wounds with large areas of skin loss were closed at ten to four¬ 
teen days with split-thickness skin grafts. The mesh graft proved to be one of the 
most effective methods of secondary wound closure in treating Vietnam casualties 
with skin loss of the feet. 

Pedicle grafts were rarely indicated in the treatment of foot wounds, since the 
failure rate of resurfacing the foot with this method was high. Even though they 
could provide a pad over the weightbearing areas of the forefoot and heel, pedicle 
grafts were anesthetic and did not wear well with weightbearing and use. At Fitzsi- 
mons General Hospital in Denver, Colorado, between 1966 and 1970, a pedicle 
graft was used in 4 of the 104 patients treated for open wounds of the foot (Ballard 
1966-70). In three, the graft was designed to replace the loss of the heel pad; in the 
fourth, it was designed to replace the skin over the ball of the foot. Three of the 
pedicle grafts failed, and the procedure was aborted after the first stage in the 
fourth case because the wound had already closed by granulation tissue, before the 
pedicle was ready to be transferred. 

Case 1: A twenty-three-year-old soldier sustained an injury to the right foot when 
he stepped on a land mine in Vietnam. This resulted in a comminuted fracture of the 
calcaneus and loss of the major portion of the heel pad. At initial debridement on 2 
March 1967, the calcaneus was removed and the wound was left open. On 16 March 
1967, a pedicle flap was raised on the left calf and was implaced on the left heel on 6 


WOUNDS OFTHE FOOT 


87 


April 1967. The wound became grossly infected and the entire pedicle flap was lost. 
The patient underwent a below-the-knee amputation on 2 June 1967 and was ambu¬ 
latory without external support or discomfort three months later. 

Case 2: A twenty-year-old soldier sustained a bullet wound in the left heel in Viet¬ 
nam on 29 December 1965. This resulted in a comminuted fracture of the calcaneus 
and loss of the posterior aspect of the heel pad. After initial debridement, which in¬ 
cluded removal of portions of the calcaneus, the wound was left open. A split-thick¬ 
ness skin graft was used to close the wound on 25 January 1966. A cross-leg.pedicle 
graft was applied to the left heel on 25 February 1966. The graft had a 75 percent 
take, and the remaining area granulated in. Sixteen months later, the patient returned 
to the hospital because of repeated breakdown of the pedicle flap and continuous 
pain with ambulation. During that period, the patient required the use of crutches or 
a cane. Three months after a below-the-knee amputation, the patient was ambulatory 
in a patellar tendon-bearing prosthesis, without external support and without pain. 

Case 3: A twenty-year-old soldier sustained a gunshot wound to the right heel on 6 
January 1968. In addition to loss of most of the heel pad, the patient had a comminuted 
fracture of the calcaneus. Most of the calcaneus was removed at the initial debridement. 
On 8 January 1968, a pedicle graft from the left calf to the right heel was done. Five 
days later there was purulent drainage from beneath the pedicle graft and most of the 
pedicle graft was nonviable. The entire graft was removed. On 20 January 1968, a mesh 
split-thickness skin graft was applied to the heel defect, with a 90 percent take. The re¬ 
maining portion of the open wound closed by granulation. By 19 August 1968, the 
wound was completely closed and the patient was ambulatory, wearing a special shoe 
with a soft heel insert and using a cane. The patient returned to the hospital in March 
1969, because of constant pain in the foot and repeated breakdown of the heel area. A 
below-the-knee amputation was done on 4 April 1969. By 16 June 1969, the patient was 
ambulatory without external support in a patellar tendon-bearing prosthesis. He had no 
pain in the extremity at that time and continued to be a good prosthesis wearer. 

Case 4: A twenty-four-year-old soldier sustained an injury to his left foot on 30 
November 1966, when he accidentally discharged a 12-gauge shotgun into the dor- 
somedial aspect of his forefoot. In addition to destruction of the distal end of the 
first metatarsal bone and first metatarsophalangeal, the patient had a 3 x 3 cm. skin 
defect over the plantar weightbearing surface of the foot. Following initial debride¬ 
ment, the wounds were left open and subsequently remained clean. On 5 January 
1967, when the flap was ready for insertion into the foot, the plantar wound had 
completely healed, and the patient was ambulating without discomfort. The pedicle 
flap procedure was aborted. 


SPECIFIC INJURIES 
Puncture Wounds 

The enemy found an inexpensive and effective means of temporarily inactivat¬ 
ing a large number of American troops through the use of sharpened, sometimes 
fire-tempered, bamboo stakes. These sticks, pushed into the ground at an angle, 
were hidden by the high grasses and underbrush especially prevalent in the high¬ 
lands area of Vietnam. These devices could puncture the fabric sides and rubber 


88 


ORTHOPEDIC SURGERY IN VIETNAM 


soles of the jungle boots worn by the American soldier and enter the foot to various 
depths. The resulting wound was usually a small (1 cm.) innocuous-appearing lacer¬ 
ation on the side or plantar surface of the foot (fig. 23). Early in the Vietnam con¬ 
flict, since the potentially serious nature of these wounds was not fully appreciated, 
the treatment often was not effective. The devastating effectiveness of this simple 
weapon was recognized only after many patients returned to the medical facilities 
with deep infections of the foot. These patients required weeks, and sometimes 
months, of hospitalization; some acquired prolonged or permanent disability. 



Figure 23.—Medial plantar wound from bamboo stake penetration into the deep plan¬ 
tar compartments resulting in deep wound infection. 


A thorough investigation was conducted concerning the characteristics of these 
puncture wounds, the most efficacious methods of preventing potential morbidity, 
and their effective management. Microscopic examination of the tissue taken from 
along the wound tracks revealed multiple small retained slivers of bamboo sur¬ 
rounded by microabscess formation. Once this type of damage was recognized, a 
more vigorous treatment program was instituted (figs. 24 and 25). It consisted of: 

(1) longitudinal incisions extending the wound or separate anatomic incisions 
on the nonweightbearing plantar surface, thus allowing for exploration in the deep 
compartments of the foot 

(2) complete excision of contaminated tissue adjacent to the wound track 
throughout its length 

(3) thorough irrigation ot the wound with saline solution, flushing out clot and 
retained foreign bodies 


WOUNDS OFTHE FOOT 


89 



Figure 24. The skin incision for exploration of the plantar foot compartments avoids 
the primary weightbearing surface prominences. 



Figure 25.—The laciniate ligament retracted, exposing the posterior tibial nerve. 




90 


ORTHOPEDIC SURGERY IN VIETNAM 


(4) with the wound left entirely open after the initial debridement, application of a 
bulky pressure dressing, and elevation of the foot for ten to fourteen days postoperatively 

(5) intravenous antibiotics, usually 10 to 20 million units of penicillin, preopera- 
tively and for the first five days postoperatively 

(6) tetanus toxoid boosters preoperatively, and reexamination of the foot in the 
operating room five to seven days after initial debridement. 

If there was no clinical evidence of infection, many of these wounds were closed 
at the second look operation. Despite these efforts, many of the plantar wounds 
that had penetrated into the deep compartment of the foot subsequently became 
infected and broke down. As more experience was gained with this injury, most of 
these wounds were left open to heal by secondary intention. This provided an open 
track for ready egress of blood and purulent material. The incision on nonweight¬ 
bearing areas of the plantar surface of the foot healed well by secondary intention, 
leaving a thin-line scar that was both cosmetically and functionally acceptable. 

Hindfoot Wounds 

The hindfoot, consisting of the talus, calcaneus, and heel pad, absorbs the initial 
shock of impact in the stance phase of gait. The heel pad is remarkably designed for this 
function. Multiple fibrous septa attaching to the calcaneus envelop fat lobules that, 
when compressed, flatten and expand laterally within the limits of the fibrous septa and 
skin. This arrangement is similar to a pneumatic tire. If injury or infection has badly 
damaged the fat lobules and they have been replaced by fibrous scar tissue, the heel pad 
loses its shock-absorbing qualities and functions like a deflated pneumatic tire. 

The heel pad also allows for accommodation of the foot to rough or irregular 
surfaces and is effective in limiting friction between the skin and the shoe or 
ground, when the foot changes direction of travel. It does this by shifting for a lim¬ 
ited distance, medially and laterally, a function sometimes referred to as the third 
joint of the ankle. 

The heel pad is innervated largely by the medial calcaneal branch of the tibial 
nerve, which pierces the posterior superior aspect of the laciniate ligament to run 
subcutaneously alongside the distal Achilles tendon and enters the heel pad on its 
medial posterior surface. Incision in this area should be planned carefully to avoid 
injury to this important sensory nerve. 

Blood to the heel pad is supplied from anastomoses of the lateral calcaneal 
branch of the peroneal artery and the medial calcaneal branch of the posterior tibial 
artery. The latter vessel, which provides the major portion of the flow to this anasto¬ 
mosis, should be carefully preserved when incisions in this area are made. Damage 
to this vessel is a common cause of necrosis of the heel pad in Syme’s amputations. 

The talus is also important to gait for it not only transmits all of the body weight 
to the foot but also serves as a center of motion around which most of the dorsiflex- 
ion-plantarflexion and inversion-eversion occur. The talus has no muscular attach¬ 
ments, so its only connection to adjacent structures is by synovial membrane, artic¬ 
ular capsules, and ligaments. The talus has a precarious blood supply that enters the 
bone primarily through vascular foramina about the neck (Giannestras 1973, 29). 
Fractures through the neck of the talus threaten the talus body with avascular 


WOUNDS OFTHE FOOT 


91 


necrosis (Hawkins 1970). The talus articulates with four bones: tibia, fibula, calca¬ 
neus, and navicular. Damage to any one of these articulations can result in alter¬ 
ation of gait and inability of the foot to accommodate to irregular surfaces. 

In Vietnam casualties, badly comminuted open fractures of the talus were 
treated by initial talectomy. Any large fragments left behind after debridement, ex¬ 
cept possibly the talar head and neck, were found to sequester and became a source 
ot chronic infection (Hawkins 1970). The most useful approach for debridement of 
the talus or talectomy was an anterior lateral ankle incision. This allowed dissection 
completely around the talus. The skin incision began 2 to 3 inches (5 to IVi cm.) 
above the ankle joint medial to the fibula and was carried distally over the superior 
aspect of the calcaneal cuboid joint to the base of the third or fourth metatarsal. If 
possible, the skin incision was altered to incorporate the wound. If this was not fea¬ 
sible, the entry and exit skin wounds were debrided separately, with the internal de¬ 
bridement through the elective incision. 

Then, the transverse and cruciate crural ligaments were divided in the direction 
of the skin incision. The ankle joint capsule was excised anteromedially and later¬ 
ally. The fragmented talus was excised, leaving the head and neck, if possible. Care 
was taken to preserve the dorsalis pedis artery, since a penetrating gunshot wound 
of the hindfoot frequently damaged the posterior tibial and peroneal vessels. After 
debridement, the wounds were left open and were dressed, and the foot was 
splinted for stability. 

At the second look procedure five to seven days later, if the wound was clean, the 
hindfoot was shifted posteriorly to place the remaining portions of the talus and part 
of the posterior aspect of the navicular beneath the distal end of the tibia. Large 
Steinmann pins were driven through the calcaneus into the tibia to stabilize the foot 
in this new position (fig. 26). The anterior lateral incision was closed but the other 
wound areas were left open. The pins were left in situ for six weeks and following pin 
removal, ambulation was begun in a well molded patellar tendon-bearing cast. 

The calcaneus forms the shorter and less yielding posterior limb of the longitudi¬ 
nal arches of the foot (Giannestras 1973, 28). It articulates with the talus, above, and 
the cuboid, distally. Intraarticular fractures of the calcaneus result in compromise of 
the hindfoot inversion-eversion and forefoot pronation-supination. Extraarticular 
fractures are frequently associated with damage to the heel pad and the problems re¬ 
sulting from injury to this structure. The blood supply to calcaneus is multisource 
and extensive. Aseptic necrosis of any portion of this bone is uncommon. 

Penetrating wounds through the plantar surface of the heel pad were explored 
and debrided through a modified Gaenslen heel-splitting incision (Gaenslen 1931). 
This approach split the fat pad longitudinally and allowed access to the underlying 
comminuted contaminated calcaneus (fig. 27). All identifiable contaminants and 
small fragments of bone and cartilage were removed. The lateral, medial, and poste¬ 
rior shells of the calcaneus with its soft tissue attachments were preserved, if possi¬ 
ble. Undermining the heel flaps was kept to a minimum since this further impaired 
the neurovascular supply to the structure and destroyed the shock-absorbing capac¬ 
ity of the heel pad. Internal fixation of fracture fragments of the calcaneus was con¬ 
sidered contraindicated because of the high incidence of osteomyelitis. Following 
surgical debridement, the wound was flushed with normal saline or an antibiotic so¬ 
lution and left open. No attempt at secondary closure was made in these wounds. 


92 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 26. —Shotgun wound of the ankle, 
with destruction of the talus and fracture of 
the calcaneus. Primary talectomy was done at 
the initial debridement. The head of the talus 
and part of the navicular were shifted posteri¬ 
orly under the tibia and fixed with Stein- 
mann’s pins. Two years later the hindfoot had 
healed and a foot and ankle were preserved. 





WOUNDS OFTHE FOOT 


93 



The side-to-side traversing gunshot wound of the hindfoot was most adequately 
debrided through lateral and medial incisions, with the major portion of the explo¬ 
ration through the lateral incision. This procedure avoided further damage to the me¬ 
dial calcaneal branches of the posterior tibial nerve and to the tibial artery that sup¬ 
plied the heel pad. A medial incision through the fat pad was prone to transect the 
calcaneal branches of the posterior tibial nerve, rendering the majority of the heel pad 
anesthetic. These wounds were left open, appropriately dressed and splinted. Healing 
of wounds of several centimeters in size occurred quite readily by ingrowth of sur¬ 
rounding epithelium over the framework of the underlying granulation tissue (fig. 28). 
Well molded circular casts were applied, and ambulation was allowed as the wound 
condition permitted. A patellar tendon-bearing cast applied over a one inch (2.5 cm.) 
thick sponge rubber pad placed over the plantar surface of the foot helped to decrease 
the forces transmitted through the hindfoot and allowed for early ambulation. 

The final hindfoot wound discussed in this section is the injury in which the heel 
pad and the underlying bones were irreparably damaged. The sentiments of Hamp¬ 
ton after World War II are still applicable: 

Compound fractures of the tarsus, especially when the os calcis was involved, 
were a source of prolonged disability. Functional results were seldom optimal and 
were often actually poor. Although conservatism was ordinarily practiced, many or¬ 
thopedic surgeons, when they reviewed their experience, wondered whether this had 
been the wisest course. They could recall many cases of extensive bony disorganiza¬ 
tion and persistent infection, with continuing destruction of bone or loss of weight¬ 
bearing skin on the plantar surface of the heel, in which conservative measures had 
been employed but in which amputation might have been the wiser course. In some 
of these cases, amputation was eventually performed in the Zone of Interior but 
only after the soldiers had been hospitalized for months and even years. 



94 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 27. —Longitudinal heel-splitting incision used to debride infected calcaneus 
and plantar heel wounds. 


If Hampton’s advice had been followed by the surgeons treating patients with 
this injury sustained in Vietnam, rehabilitation of the patient would have been 
more rapid and successful. Amputation should be done before the surgeon and the 
patient become so emotionally attached to the foot that their goals become unreal¬ 
istic. The amputation, therefore, should be done at the initial debridement or at the 
second-look operation (fig. 29). 

Statistics on foot injuries during the Vietnam War are not available for analysis; 
therefore, the results of treatment of hindfoot injuries from a major hospital are re¬ 
ported as representative of this type of wound. Twenty-four patients with twenty- 
six significant hindfoot injuries were treated at Fitzsimons General Hospital during 


1966-70 with results as follows: 

Returned to: 

Duty w/o symptoms. 2 

Limited duty w/symptoms. 5 

Total returned to duty. 7 

Discharged as unfit for duty: 

Ambulatory without assistance or pain. 1 

Ambulatory with pain and assistance. 8 

Early amputation (first hospitalization). 3 

Delayed amputation (subsequent hospitalization). 5 

Total Discharged. 17 

Total Patients. 24 











WOUNDS OFTHE FOOT 


95 




Figure 28. —Perforating gunshot wound of heel. Wound left open after debridement 
and four weeks later, healing by centripetal epithelialization. 





96 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 29.—Gunshot wound to hindfoot with severe damage to the calcaneus and nerves 
and arteries of the heel pad. Best treatment would have been below-knee amputation. 


In general, these patients with hindfoot injuries were treated until final disposi¬ 
tion so that the end results reported here probably represent their eventual condi¬ 
tion. The hospital stay for this group of patients ranged from 28 to 625 days, averag¬ 
ing 246 days. Of the 17 patients medically unfit for further military service and 
discharged, 8 had significant pain and required external support for ambulation; 1 
had a spontaneous ankle fusion, denied pain, but had an altered gait; 3 had below- 
knee amputations early in their stay at the hospital; and 5 returned to the hospital 
within three years and requested below-knee amputations, which were done. 

Midfoot and Metatarsal Area Wounds 

The midfoot, composed of five small tarsal bones, roughly resembles a wedge 
with the apex laterally and the base medially. Through and about these five bones, 
part of the movements of pronation and supination occurs. They augment the in¬ 
version and eversion that take place through the subtalar joints. These bones form 
the apex of the longitudinal arch of the foot (Grant 1952, 444-48). Surgically, the 
dorsum of the midtarsal and metatarsal areas was approached through appropriate 
longitudinal incisions. 

The deep plantar artery joins the lateral plantar artery from the posterior tibial 
artery to form the plantar arterial arch. At the base of the second and third 
metatarsals the artery branches into the first dorsal metatarsal artery and the deep 
plantar artery. Care was taken to identify and preserve the dorsalis pedis artery as it 


WOUNDS OFTHE FOOT 


97 


crossed the dorsum oi the midfoot lying in turn on the talus, lateral side of the nav¬ 
icular, and second cuneiform. 

At the second-look operation or at a later date when the wound was determined 
to be clean, internal fixation with small Kirschner wires was used to align displaced 
skeletal parts. The Kirschner wires were cut off below the skin so that they could be 
readily retrieved later. Stability in the position of function gave the best chance of 
useful future foot function. When the injured tissue stabilized and edema de¬ 
creased, the initial cast or splints were replaced with a well molded plaster cast. 
Weightbearing ambulation was begun when some bone stability had been achieved, 
usually six to eight weeks after injury. Fractures of the distal metatarsals allowed 
much earlier weightbearing, usually within a few days of injury. The surgical ap¬ 
proach to the plantar surface of this area is described later in this chapter. 

At Fitzsimons General Hospital during 1966-70, 60 patients with open injuries 
of the midfoot or metatarsal areas or both were treated, with the following results: 


Returned to duty: 

Without symptoms. 4 

Limited duty with symptoms. 22 

Total returned to duty. 26 

Discharged as unfit for duty: 

Ambulatory without significant symptoms. 5 

Significant symptoms requiring crutch or cane. 29 

Total discharged. 34 

All patients. 60 


Most of these patients were treated until a final disposition could be deter¬ 
mined. Except for those who returned later for amputation, the results reported 
here are probably representative of the final results from these types of injuries. 
The initial hospitalization of this group of 60 patients was from 6 to 839 days, with 
an average of 193 days. Of 26 patients returned to duty, 22 were asymptomatic and 
walking with no external support. Four were returned to a permanent limited duty 
status, and all 4 had symptoms of limited foot motion. 

Thirty-four patients were unfit for active duty at the end of their hospitalization. 
Twenty-nine of this group were symptomatic and required either a cane or crutch for 
ambulation. Ten of the 29 patients returned to the hospital within 4 years for an am¬ 
putation of the foot. Whether others of this group went elsewhere for subsequent 
ablative procedures is not known. Five patients had minimal discomfort and re¬ 
quired no external support to ambulate but were unfit for duty because of marked 
limitation of motion, anesthetic portions of the feet, or significant plantar skin loss. 

Sixteen of the sixty patients had an amputation of a portion or all of the foot 
during their first hospitalization (table 3). Two patients who were discharged with 
Chopart amputations returned to the hospital later because of persistent equino- 
varus deformity of the stump, poor ambulatory ability, and pain with ambulation 
(fig. 30). Five patients had resections of the outside rays of the foot during their first 
hospitalization; three had the medial second or third rays resected and two had re¬ 
section of the lateral two rays (fig. 31). Two of the patients with medial ray resec¬ 
tions returned to the hospital later for a revision to a Syme’s amputation because of 









98 


ORTHOPEDIC SURGERY IN VIETNAM 


pain and poor ambulatory capacity (fig. 32). The final status of the third patient 
with medical ray resection is not known. 


Table 3. —Amputations during first hospitalization for midfoot metatarsal injury, 
Fitzsimons Genera! Hospital, 1966-70 


Patient 

Age 

Mechanism of injury 1 

Reason for amputation 

Amputation type 

1. 

21 . 

. MFW. rocket. . . 

. Open Fx Midmetatarsals 2, 3, 4. 5. 

. . 4th, 5th rays. 

2. 

20 . 

. AK-47, GSW . . 

. Destruction of midfoot. 

. . Syme’s. 

3. 

25 . 

. Land mine. 

. Loss of medial forefoot. 

. . Syme’s. 

4. 

23 . 

. Vehicle. 

. Crush injury, swelling, gangrene. 

. . Transmetatarsal. 

5. 

22 . 

. AK-47, GSW . . 

. Destruction midfoot & proximal metatarsal. . 

. . Syme’s. 

6. 

36 . 

. MFW, mine.... 

. Destruction metatarsals 1,2. 

. . 1, ray resection. 

7. 

18 . 

. Land mine. 

. Loss of forefoot. 

. . Syme’s. 

8. 

20 . 

. Land mine. 

. Destruction of midfoot. 

. . Syme’s. 

9. 

21 . 

. Vehicle, tank. . . 

. Crush & Lisfranc dislocation, gangrene. 

. . Syme’s. 

10. 

20 . 

. Shotgun, 12-ga . 

. Midfoot destruction. 

. . Chopart. 

11. 

26 . , 

. MFW. rocket. . . 

. Destruction metatarsals 4, 5. 

. . Resection rays 

3, 4, 5. 

12. 

20 . . 

, MFW, mine. . . . 

. Destruction metatarsals 1.2, 3, 4. 

. . Chopart. 

13. 

19 . . 

. Vehicle, truck . . 

. Crush both feet, gangrene left, stiff right. 

. . Syme’s left. 

14. 

19 . . 

. MFW. mine. . . . 

. Destruction medial forefoot. 

. . Resection rays 
1,2,3. 

15. 

24 . . 

MFW. mine. 

. Fx midfoot, uncontrolled deep infection. 

. Below knee. 

16. 

25 . . 

MFW. mine. 

. Destruction rays 1, 2, 3. 

. Resection rays 
1,2,3. 


1 MFW = multiple fragment wound; GSW = gunshot wound. 
Source: Author's personal records. 


Ten of the patients previously treated at Fitzsimons General Hospital and dis¬ 
charged as unfit for further duty returned to the hospital later for revision of a pre¬ 
vious amputation or for a primary amputation (table 4). A Syme's amputation was 
done on four of the patients who had previously undergone partial medial foot re¬ 
sections and whose Chopart amputation was unsatisfactory. 

Omer and Pomerantz (1972) reported the results of the management of severe 
open injuries and traumatic amputations of the foot. Of the 410 patients treated from 
1966 to 1969 at Brooke General Hospital, San Antonio, Texas, 307 had sustained 
major foot injuries. Of the 307 patients, 171 (55 percent) had assisted painful ambula¬ 
tion or had elected an amputation by the end of their first hospitalizations (table 5). 

Toe Wounds 

In the toot, unlike the hand, stability takes precedence over motion, and bone bal¬ 
ance is of greater importance than muscle balance. The foot supports and propels the 
body forward in an upright posture. The foot functions principally while it is on the 
ground. The toes press against the sole of the shoe or the ground and establish a point 
Irom which forward propulsion occurs. The toes also provide protection for the 
metatarsal heads. Both in function and structure, the great toe differs from the lesser 













































WOUNDS OFTHE FOOT 


99 



Figure 30. —Chopart amputation with common equinovarus deformity of the hindfoot. 



Figure 31. —Loss of the lateral rays 
is compatible with fair foot function. 












100 


ORTHOPEDIC SURGERY IN VIETNAM 


toes. While the lesser toes contribute to the stability of the walking base, the great toe 
is the base from which the body is propelled forward (Kelikian 1965,27-30). 


Table 4. —Amputations or revisions at subsequent hospitalization for midfoot or metatarsal injury, 

Fitzsimons General Hospital, 1966-70 


Patient 

Age 

Previous amputation 

Reason for amputation or revison 1 

Amputation type 

10. 

20 . 

. Chopart. 

. Pain with ambulation, equinovarus deformity . 

, Syme’s. 

16. 

25 . 

. Ray resection . . 
1,2,3 

. None. 

. Pain lateral side of foot, poor gait. 

. Syme’s. 

17. 

22 . 

. Deep infection post MFW, cavus foot. 

claw toes, pain 

Syme’s. 

12. 

20 . 

. Chopart. 

. Pain with ambulation, equinovarus deformity . . 

Syme’s. 

13. 

19 . 

. None, right .... 

. Lack sensation distal forefoot, stiff, painful foot . 

Transmetatarsal. 

14. 

19 . 

. Ray resection . . 
1,2,3 

. Poor walking tolerance, pain lateral foot. 

Syme’s. 

15. 

24 . 

. None, left. 

. Chronic osteomyelitis, pain, left foot post. 

MFW, midfoot 

Syme’s. 

18. 

24 . 

. None. 

. Chronic osteomyelitis, pain, MFW, midfoot. . . . 

Syme’s. 

19. 

25 . 

. None. 

. Chronic osteomyelitis, pain, GSW, midfoot . . . . 

Syme’s. 

20. 

22 . 

. None. 

. Loss sensation forefoot, cavus, stiff, painful foot . 

Syme’s. 


1 MFW = multiple fragment wound; OSW = gunshot wound. 
Source: Author’s personal records. 


Table 5. —Results after first hospitalization, open injuries of the foot, Brooke Army Medical Center, 1966-69 


Mechanism of injury 

Ambulation 
without pain 

Assisted painful 
ambulation 

Amputation 

Number 
of cases 

Major: 

Automobile. 

1 

0 

0 

1 

Bicycle (spokes). 

9 

0 

2 

11 

Burns. 

0 

3 

4 

7 

Crush and bursting. 

18 

19 

0 

37 

Gunshot wounds. 

59 

22 

21 

102 

Land mines and fragments . . 

38 

42 

48 

128 

Lawn mower. 

8 

1 

9 

18 

Motorcycle. 

3 

0 

0 

3 

Minor: 

Abrasions and contusions. . . 

54 

0 

0 

54 

Lacerations and punctures . . 

49 

0 

0 

49 

Total. 

239 

87 

84 

410 


Source: Omerand Pomerantz, 1972. 


A large proportion of toe wounds were self-inflicted by a few soldiers seeking 
relief from duty. Most frequently, the left foot was involved and, fortunately, the 
lesser toes were most commonly injured. Despite the high velocity of the rifles used 
in Vietnam, damage was usually confined to a limited area, probably because the 
toes offer little impedance to the passage of a bullet and thus little energy was ex- 







































WOUNDS OFTHE FOOT 


101 



Figure 32. —Loss of the medial rays results in poor foot function and should be con¬ 
verted to a Syme’s amputation. 


pended within the part. Throughout the Vietnam War, periodic attempts were 
made to keep the soldiers with a self-inflicted wound in the zone until they could be 
returned to duty. Unfortunately, these wounds took several weeks to heal suffi¬ 
ciently to allow full combat duty and, if retained in Vietnam, the hospitalized pa¬ 
tient could not be replaced with a more effective soldier. 

Since the great toe is important in normal gait, every effort was made to preserve 
its function. After debridement, when the wound was determined to be clean and 
ready for closure, small Kirschner wires were used to align and stabilize the fractures. 
The interphalangeal joints of the first toe were fused without great loss of function, but 
mobility of the metatarsophalangeal joint was preserved, if possible, either by resec¬ 
tional arthroplasty in Vietnam, or, at some CONUS centers, by use of artificial partial 
or complete first metatarsophalangeal joints. The artificial joint was more stable than 
the resection arthroplasty and thus provided a better axis around which the muscles of 
propulsion could work. Implants had no place in the initial surgery of combat casual¬ 
ties and were reserved for reconstruction at a later time in the clean closed wound. 

Loss of the first toe was frequently associated with damage to the intrinsic mus¬ 
cles of the foot, leading to a claw toe deformity of the lesser toes. These digits then 
not only became functionless, but further impaired the wearing of footgear and am¬ 
bulation. Such patients were much better off with amputation of all toes rather than 
with the preservation of stiff, deformed claw toes. 





102 


ORTHOPEDIC SURGERY IN VIETNAM 


Twenty patients with open injuries involving, primarily, the toes were treated at 
Fitzsimons General Hospital from 1966-70 with results as follows: 


Returned to duty: 

Without symptoms. 13 

Limited duty without symptoms. 0 

Total returned to duty. 13 

Discharged from service: 

Amputation of first toe. 4 

Amputation of second toe with hallux valgus. 2 

Claw toe. 1 

Total discharged. 

All patients. 20 


Hospitalization of these 20 patients varied from 4 to 270 days (average, 71 days). 
The prolonged hospitalization—270 days—was for a patient who had sustained a 
crush injury of the first toe that resulted in an open comminuted fracture of both pha¬ 
langes and loss of the medial plantar skin of the toe. Prolonged infection ensued, and 
the toe was eventually amputated. Thirteen patients from this group were returned to 
full duty without significant symptoms. Of the 7 patients discharged from the service 
as unfit for duty, 4 had lost the first toe, 2 had the second toe amputated with subse¬ 
quent valgus drift of the first toe, and 1 had severe clawing of the middle 3 toes and 
marked metatarsalgia. All patients with loss of function of the first toe had an altered 
gait, required modified footgear, and were unable to run effectively (fig. 33). 

RECOMMENDED OPERATIVE APPROACH TO DEEP 
COMPARTMENTS OF THE WOUNDED FOOT 

A high percentage of patients with open injuries of the foot suffer from pro¬ 
longed disability. Part of the morbidity resulting from foot wounds sustained in Viet¬ 
nam was attributable to inadequate initial debridement and subsequent deep foot 
infections. As experience accumulated, greater use was made of plantar incisions, 
which facilitated better exposure of the damaged area and afforded greater protec¬ 
tion of the undamaged tissues. One particularly useful approach, all or any portion 
of which may be used to explore the plantar aspect of the foot, is described below. 

Initially, an incision is made in the skin 1.5 inches (3.8 cm.) proximal and 1 inch 
(2.5 cm.) posterior to the tip of the medial malleolus. It is extended distally and plan- 
tarward to run just in front of the heel pad and then along the longitudinal plantar 
arch to a point between the second and third metatarsal heads. This incision roughly 
parallels the course of the medial plantar nerve. The neurovascular bundle lies 
below the laciniate ligament and posterior to the flexor digitorum longus tendon and 
can be readily identified behind the medial malleolus. At the superior edge of the 
laciniate ligament, the tibial nerve divides into two terminal branches, the medial 
plantar nerve and lateral plantar nerve. The laciniate ligament should be divided 
over the flexor digitorum longus tendon to avoid damage to the medial calcaneal 
branch ol the tibial nerve, which passes through the superior posterior aspect of the 
ligament, near its attachment to the calcaneus. The medial and the lateral plantar 










WOUNDS OFTHE FOOT 


103 



Figure 33.—The skin of toes 2, 3, and 4 has been used to resurface the plantar area 
over the metatarsal heads. The fifth toe was later amputated. The medial and plantar 
areas of the arch have been covered with split-thickness skin graft; the metatarsal head 
area with skin from the filleted small toes. The great toe was destroyed in the injury. 

nerves, accompanied by the posterior tibial artery, pass deep to the abductor hallucis 
muscle and enter the plantar surface of the foot between this muscle and the flexor 
digitorum brevis. They are best exposed and protected by excising the origin of the 
abductor hallucis from the calcaneus. A suture ligature placed through the free end 
of the muscle is used to retreat it distally and medially. 

The medial plantar nerve supplies sensation to the medial three-fourths of the sole 
of the foot. In its course through the foot, the medial plantar nerve lies deep to the 
flexor digitorum brevis muscle and superficial to all other muscles and tendons of the 
foot. Beneath the abductor hallucis, the medial plantar gives off two or three muscular 
branches to the deep surface of this muscle at its middle and distal thirds. Distal to the 
muscular branches, it divides into three common digital nerves, each of which splits into 
two proper digital nerves to supply the first, second, third, and one-half of the fourth 
toes. This terminal division occurs just proximal to the transverse metatarsal ligaments. 

The lateral plantar nerve supplies sensation to the lateral one-fourth of the sole of 
the foot and provides motor branches to most of the deep intrinsic muscles of the foot. 
Upon exiting from beneath the abductor hallucis muscle, it runs obliquely laterally and 
distally in the interval between the flexor digitorum brevis muscle and the quadratus 
plantae muscle. The large lateral plantar artery accompanies this nerve. By transecting 
the origin of the plantar aponeurosis and flexor digitorum brevis from the calcaneal 
tuberosity and retracting these structures, laterally, and the abductor hallucis muscle 
medially, the midfoot course of the medial and lateral plantar nerves and arteries can 
be exposed and protected. The relationship of these structures is shown in figure 34. 








ORTHOPEDIC SURGERY IN VIETNAM 



Figure 34.—Transection of the origins of the 
abductor hallucis and flexor digitorum brevis 
muscles allows retraction for further visualiza¬ 
tion of the plantar nerves and vessels. 











WOUNDS OFTHE FOOT 


105 


A suture ligature placed in the cut end of the flexor digitorum brevis is helpful in 
retraction and exposure. The medial plantar nerve and artery are retracted medially 
and the lateral nerve and artery are retracted laterally along with the flexor digito¬ 
rum brevis. The quadratus plantae muscle inserting into the flexor digitorum longus 
tendon now lies in the floor of the wound. Access to the third layer of muscles, to the 
deep plantar ligaments, and to the bones and joints is gained by transecting the in¬ 
sertion of the quadratus plantae along with a narrow strip of the flexor digitorum 
longus tendon and retracting this structure, laterally. By retracting the flexor digito¬ 
rum longus tendons medially the plantar aspect of the foot, from the calcaneal 
tuberosity to the mid-metatarsal areas, can be exposed. Running a course from prox¬ 
imal lateral to distal medial in the floor of the wound are the peroneus longus ten¬ 
don and the deep branch of the lateral plantar artery. The lateral plantar artery 
unites with the deep plantar branch of the dorsalis pedis artery in the interval be¬ 
tween the bases of the first and second metatarsals to complete the plantar arterial 
arch. Interruption of this vascular arch at any site is compatible with survival of the 
distal foot, but unrelieved pressure from midfoot swelling will result in necrosis and 
loss of the forefoot. By extending the incision distally, through the second and third 
web spaces, the second, third, and fourth metatarsal areas can be explored readily. If 
exposure of the first or fifth metatarsal is indicated, separate incisions are required. 

SUMMARY 

The prolonged morbidity and ultimate high incidence of permanent disability of 
foot wounds were not fully appreciated by many surgeons during the Vietnam War. 
Inadequate debridement of wounds through inappropriate surgical exposures con¬ 
tributed to the poor results. Some of the lessons learned by experience in treating 
foot wounds were: 

(1) Contamination of the deep plantar compartments of the foot necessitated 
thorough debridement, which was best done through plantar incisions. These inci¬ 
sions allowed protection and preservation of the important neurovascular struc¬ 
tures and removal of contaminants and devitalized tissue. 

(2) Wounds causing loss of the heel pad were best treated by early below-knee 
amputations. 

(3) Some medical centers achieved satisfactory results from Chopart-type midfoot 
amputations by carefully balancing muscle forces about the ankle and with appropriate 
partial foot prosthesis. However, in most treatment facilities, the majority of patients 
with severe forefoot wounds were better served by a Svme’s amputation that reduced 
the length of morbidity, the number of surgical procedures, and prosthetic revisions. 

REFERENCES 

CINCPAC-3. 1969. Commander in Chief, Pacific. Third CINCPAC Conference on 

War Surgery. Tri-service conference conducted at Camp H.M. Smith, Hawaii, 

20-23 Jan 1969. 

Gaenslen, F. J. 1931. Split-heel approach in osteomyelitis of os calcis. J. Bone Joint 

Surg. 13:759-72. 


106 


ORTHOPEDIC SURGERY IN VIETNAM 


Giannestras, N. J. 1973. Foot disorders: medical and surgical management. 2d ed. 
Philadelphia: Lea & Febiger. 

Grant, J. C. B. 1952. A method of anatomy: descriptive and deductive. 5 th ed. Balti¬ 
more: Williams & Wilkins. 

Gray, H. 1959. Anatomy of the human body. 27th ed. Philadelphia: Lea & Febiger. 
Hampton, O. P, Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Oper¬ 
ations. Office of The Surgeon General, Department of the Army. Washington: 
GPO. 

Hawkins, L. G. 1970. Fractures of the neck of the talus. J. Bone Joint Surg. 52- 
A:991-1002. 

Kelikian, H. 1965. Hallux valgus, allied deformities of the forefoot and metatarsalgia. 
Philadelphia: W. B. Saunders. 

Lavenson, G. S., Jr.; Rich, N. M.; and Strandness, D. E., Jr. Ultrasonic flow detector 
value in combat vascular injuries. Ann. Surg. 102:644-47. 

MD-OSMTO—Medical Department, U.S. Army. 1957. Orthopedic surgery in the 
Mediterranean Theater of Operations. Surgery in World War II. Washington: 
GPO. 

Omer, G. E., Jr., and Pomerantz, G. M. 1972. Initial management of severe open in¬ 
juries and traumatic amputations of the foot. Arch. Surg. 105:698. 

Rusher, R. G.; Baker, D. W.; Johnson, W. L.; and Strandness, D. E., Jr. 1967. Clinical 
applications of a transcutaneous ultrasonic flow detector. J.A.M.A. 199: 104-06. 
Strandness, D. E., Jr., and Bell, J. W. 1965. Peripheral vascular disease: diagnosis 
and objective evaluation using a mercury strain gauge. Ann. Surg. (Suppl.) 
161:3-35. 


6 


Wounds of Joints 

Colonel Anthony Ballard , MC, USA (Ret.) 


HISTORICAL BACKGROUND 

Joint injuries have traditionally presented a great challenge to physicians. Dur¬ 
ing the American Civil War over 3,000 cases of knee joint injuries were recorded. 
The extremity was amputated in 70 percent, and 53 percent died. Open joint 
wounds during that conflict were treated with hot packs and immobilization of the 
joint (MSHWR 1883). 

Early in the U.S. involvement in World War I, American surgeons treated joint 
wounds by debridement, irrigation with antiseptic solutions, and immobilization until 
the wounds healed. While this approach reduced mortality from chronic infections, it 
resulted in many complications. By the end of the conflict, surgeons had noted that 
this treatment caused fibrous ankylosis of many joints and that sterilizing the joints 
with antiseptics was not possible. In fact, many of the solutions used for sterilization, 
such as ether or a buffered aqueous solution of sodium hypochlorite containing 23 
percent active chlorine (Dakin's solution), were harmful to the synovial lining of the 
joints. The use of indwelling intra-articular catheters to drain joints was discontinued 
when it was observed that catheters were causing intra-articular damage. 

World War I surgeons also closed joint wounds whenever possible, after which 
they immobilized the limb for eight to ten days before beginning a passive range of 
motion with massage. This step partially solved the problem of stiff joints secondary 
to prolonged immobilization. Although additional treatment measures significantly 
reduced the infection rate, it still remained a major concern (MD-WW 1927,317-41). 

Immediately after the war, a Belgian surgeon. Dr. Charles Willems, proposed a 
completely different method of treating joint wounds, especially those already in¬ 
fected. He contended that there was no effective way of establishing adequate 
drainage in an immobilized joint, despite the numbers or kinds of incisions or intra- 
articular drains employed. He advocated wide arthrotomy, intra-articular debride¬ 
ment, and immediate mobilization of the joint, thus allowing the wounds to close by 
second intention. He emphasized that the active joint motion that was needed could 
not be replaced by passive motion. His results were exceptionally good. Of 20 cases 
so treated, there were no amputations, no deaths, 1 joint resection, 3 residual anky- 
losed joints, and 16 with good to normal motion. This method of treatment, while 
proven superior, required close supervision of the patient and was painful. Although 
a number of orthopedic surgeons practiced this method after World War I, it gradu¬ 
ally disappeared as a treatment regimen in the United States (Willems 1919) (fig. 35). 

The surgeons of World War II were fortunate to have the sulfas as effective 
chemotherapeutics and, later in the conflict, some antibiotics. The standard treat- 


108 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 35. —The Willem’s technique of active 
joint motion in the presence of open wounds is 
also applicable to the elbow. Skin traction to 
the forearm maintains elevation and the elbow 
in nearly full extension. The patient actively 
flexes the joint and with relaxation of muscula¬ 
ture the elbow returns to full extension. 






WOUNDS OF JOINTS 


109 



















no 


ORTHOPEDIC SURGERY IN VIETNAM 


ment for uninfected joints was thorough debridement, closure of the wounds, instil¬ 
lation of penicillin into the joint, and immobilization with splints or casts. Aspira¬ 
tion of the joint and instillation of antibiotics were carried out through a window in 
the cast. This regimen was continued as long as significant effusion persisted. The 
wound was immobilized for ten to fourteen days after wound closure, and then an 
active program of joint mobilization was initiated. The overall results from this 
treatment method were good. In one series of 198 knee joint wounds so treated, the 
incidence of infection was 5.4 percent. Complete joint destruction from infection 
occurred in only 2 percent (MD-OSMTO 1957, 235). 

OVERALL POLICY IN THE TREATMENT 
OF JOINT WOUNDS 

Early in the Vietnam conflict, the method of joint wound care varied with the 
previous experience of the treating surgeon. Since few surgeons spent longer than 
one year in Vietnam and the receiving PACOM (Pacific Command) or CONUS 
(continental United States) hospitals provided little feedback, the ability of the sur¬ 
geon treating the fresh joint wound to assess potential treatment results was poor. 
Judging from the fragmentary reports available, complications and morbidity in¬ 
creased for the first two months after the usual summer rotation “hump,” when ex¬ 
perienced surgeons left to be replaced by new draftees from CONUS. The most 
consistently followed treatment guidelines available were probably those outlined 
in the NATO Handbook, “Emergency War Surgery” (1958). These called for early 
debridement through standard arthrotomy incisions or conversion of the wound to 
an appropriate approach to allow for wide exposure of the intra-articular struc¬ 
tures. All blood clots, foreign debris, and loose bone or cartilage fragments were re¬ 
moved. The capsule or synovium was dosed whenever possible, but the skin was 
left open and the wound closed later (DOD-EWS 1958, 238-40). 

By the mid-1960s, the failings of the NATO Handbook’s approach were becoming 
apparent. Surgeons found that following the guidelines frequently resulted in a signif¬ 
icant complication rate and, contrary to the handbook s warning, exposed cartilage 
did not rapidly become necrotic. Thus, after 1966, many joint wounds were left open 
until delayed primary closure 5 to 7 days later. Closure was then done whenever pos¬ 
sible, and the joint was immobilized in appropriate splints or plaster casts for trans¬ 
portation to another medical facility. Mobilization of the joint was generally begun 10 
to 15 days after the wound was closed. Systemic antibiotics, usually 20 million units of 
intravenous penicillin a day, were continued for 10 to 14 days after wounding. 

In May 1967 in an attempt to evaluate and standardize treatment of war 
wounds, representatives of all three services met in what subsequently became 
known as the CINCPAC Conferences on War Surgery. The first of these, held at the 
John Hay Air Base in the Philippines, included orthopedic surgery representatives 
from CONUS, Hawaii, the Philippines, Japan, and Vietnam. In general, this study 
group subscribed to the treatment principles of wounded joints as described in the 
NATO Handbook (1958). 

A method employed by Maj. John Feagin at the 85th Evacuation Hospital in 
Vietnam aroused some interest (CINCPAC-1 1967, 38-39). His treatment consisted 


WOUNDS OF JOINTS 


111 


ol tight closure of the debrided joint over two catheters. Aqueous penicillin was in¬ 
stilled through a continuous drip at 5 million units a day and evacuated through the 
second catheter by gravity drainage. Surgeons also examined another and similar 
method for treating knee joints that had sustained significant tissue damage, sec¬ 
ondary to penetrating wounds. After thorough debridement of the wounded joint, 
the capsule and synovium were tightly closed, and a perforated polyethylene 
catheter was placed through separate stab wounds. The entrance of this catheter 
was superior, laterally, into the suprapatellar pouch, and the exit was anteromedial, 
just below the joint line. The skin was left open unless, because of loss of synovium 
or capsule, skin suture was required to seal the joint. Through the catheter system, 
5 million units of penicillin in 2.400 cc. of normal saline were run through the joint 
every 24 hours. The egress catheter was clamped for one-half hour every 4 hours to 
ensure optimum lavage of the joint. The catheter system was continued until the 
wound was closed at 5 to 7 days. (Feagin 1966, CINCPAC-2 1968, 71). 

Both of these methods were later found to have several drawbacks: patients 
could not be transported while the catheters were in place, catheters were fre¬ 
quently blocked, several known instances of complete synovial necrosis were 
thought to be caused by antibiotics, and gram-negative bacteria were cultured from 
the egress catheter (Feagin 1966, Whelan 1968). As a result, the second Conference 
on War Surgery recommended the deletion of the catheter method for the initial 
treatment of joint wounds. The study group also suggested loose closure of the syn¬ 
ovium at five to seven days with split-thickness grafts or skin flaps, although pri¬ 
mary closure was possible if the soft tissue had been avulsed. The group recognized 
that the joint function salvage rate would be low (less than 25 percent) using these 
methods (CINCPAC-2 1968, 71). The recommendations from the fifth and final 
CINCPAC surgical conference pertaining to joint injuries differed very little from 
those of the previous conferences (CINCPAC-5 1971, 44). 

WOUNDS OF THE KNEE 

The knee, a large, weightbearing, and poorly protected joint, is subject to injury 
in any highly active population. Such injuries account for a large portion of the 
surgery done by military orthopedic surgeons. The combat soldier is usually even 
more active than his brother in training; thus his knee is more subject to similar 
closed injuries. Patients with closed injuries, such as meniscal disruption, ligamen¬ 
tous sprains, patellar fractures, or dislocations were rapidly evacuated to PACOM 
and CONUS hospitals for appropriate treatment. Arthrotomy of knees with these 
types of injuries was discouraged in Vietnam, since return to duty as an effective 
combat soldier required weeks or months of rehabilitation. An accurate record of 
numbers and types of joint injuries and the final results of treatment is unavailable. 
Therefore, the information that follows in this section is anecdotal in nature. 

Treatment of open wounds of the knee began on the battlefield when the unit 
aidman applied a compression dressing. Since helicopter evacuation was usually 
readily available, the patient was generally at a hospital within two hours. He seldom 
had to wait more than a total of four hours from the time of wounding until defini- 


112 


ORTHOPEDIC SURGERY IN VIETNAM 


tive surgery. Rapid evacuation and early definitive treatment, probably more than 
any other factor, favorably influenced the results obtained in treating knee wounds. 

Upon arrival in the hospital receiving area, the patient underwent appropriate 
resuscitative measures and the start of intravenous fluids. He also usually received 
20 million units of penicillin, and roentgenograms of his knee were obtained before 
he was taken to the operating room. 

Operating room procedure included the initiation of anesthesia, usually spinal or 
general, and the application of pneumatic tourniquets. The extremity was shaved and 
washed with an antiseptic detergent solution circumferentially, from hip to ankle. The 
entire extremity was draped free. For small fragment or puncture wounds, anatomical 
arthrotomy approaches gained access to the interior of the joint. The wound area of 
skin, subcutaneous tissue, and capsule were debrided of a small amount of tissue, but 
the interior was examined through a formal arthrotomy approach. For large soft tis¬ 
sue wounds, the wound was extended sufficiently, both proximally and distally, to 
allow identification and protection of normal anatomical structures and visualization 
of damaged intra-articular tissues. During this process, later reconstruction of the 
joint was kept in mind. All loose intra-articular fragments of bone and cartilage were 
removed, and fragmented, torn, or detached menisci were excised. 

The joint was irrigated with copious amounts (2,000 to 3,000 cc.) of sterile saline 
or antibiotic solution. An attempt was made to reduce major intra-articular fractures, 
but they were not internally fixed at the time of initial debridement. Large attached 
bone fragments were cleansed of all obvious debris and reduced, if possible. Gener¬ 
ally, curettes and syringe irrigation were used in the debridement of large bone frag¬ 
ments. In some hospitals, however, a dental-type pulsating water jet system was used, 
an approach that gave rise to considerable controversy since some believed that the 
high pressure jet drove the contaminants further into the bone and soft tissue planes, 
while others concluded that it mechanically removed them from the area. 

Before mid-1966, surgeons in Vietnam closed the joint synovium, the capsule, or 
both when there was sufficient tissue, but left the remainder of the wound open. In 
July 1966, however, information began to filter back to them that the knee wounds 
in which neither had been closed at the initial surgery were in better condition on 
arrival at the PACOM hospitals than those in which either the capsule or the syn¬ 
ovium had been closed. These reports indicated that approximately 15 percent of 
those knees in which the synovium or the capsule had been closed initially had to be 
reexplored at the time of anticipated delayed primary closure because of joint effu¬ 
sion and suspected infection. In response, after initial debridement, Vietnam sur¬ 
geons left an increasing number of knee joints open, and dressed the wounds, first 
with a layer of fine mesh gauze and then with a bulky occlusive dressing. 

Fractures were dealt with by applying a cylinder cast which was immediately bi- 
valved for later air evacuation. Where no major intra-articular damage was sus¬ 
tained, a bulky soft pressure dressing was applied, and medial and lateral plaster 
splints were placed over the dressing, secured in place with elastic bandages. 

After immediate treatment in Vietnam, most patients with knee wounds were 
flown to offshore PACOM hospitals in the Philippines, Japan, Okinawa, or Hawaii 
within 7 days after injury. Frequently, the patients arrived dehydrated and exhausted 
from the prolonged trip through the evacuation system. The first 24 to 36 hours were 
spent, therefore, in general resuscitation of the patient, unless the clinical findings indi- 


WOUNDS OF JOINTS 


113 


cated the presence of an active infection. In these instances, the patient was taken to 
the operating room on the day of arrival for wound inspection and appropriate care. 

The remainder of the patients were not taken to the operating room until 24 to 36 
hours after arrival at the offshore hospital. With the patient under spinal or general 
anesthesia, the dressings were removed, the extremity was washed with an iodine-de¬ 
tergent solution, and the wound was examined. If the synovium and capsule had been 
previously closed and no significant joint effusion was encountered, the wound was 
closed by suture of the retinaculum and skin. If the synovium and capsule had been left 
open, the interior of the joint was inspected, irrigated with saline solution, and closed in 
layers. Penicillin (1 to 2 million units) was instilled into the joint before closing. 

Postoperative care for the knee joint wounds without major intra-articular damage 
was similar to that of elective arthrotomies. After 10 days, the bulky pressure dressing 
or plaster cylinder cast and sutures were removed and range of motion and quadriceps 
strengthening exercises instituted. After remaining in the offshore hospital for 14 to 21 
days, these patients were sent to a CONUS hospital for further rehabilitation. 

In those cases where soft tissue loss made closure with local tissue unfeasible, split¬ 
thickness skin grafts were used to cover the area. In very few cases, skin flaps were em¬ 
ployed to cover a wound. In knee joint injuries with major unstable intra-articular frac¬ 
tures, internal fixation with multiple Kirschner or Steinmann pins was attempted at the 
time of the delayed primary closure. Experience showed that if one waited until the 
wounds were healed, the bone fragments would have undergone marked osteoporotic 
changes, making secure internal fixation impossible. The fragment was likely to have 
partially healed in a poor position and, when motion was instituted, the dense periar¬ 
ticular adhesions that had formed might prove stronger than the osteoporotic bone of 
the joint. Therefore, after internal fixation, the joint was left open and a bulky occlu¬ 
sive dressing applied. The limb was kept elevated in a suspended Thomas splint with 
Pierson attachment for 5 to 7 days, then reinspected in the operating room with the pa¬ 
tient anesthetized. The wound was closed if it was clinically free of infection and if suf¬ 
ficient soft tissue remained to allow suture of the wound. If these conditions did not 
permit closure, it was delayed another 10 to 14 days, at which time a split-thickness 
skin graft was applied. These patients were generally retained in the offshore hospitals 
for 30 to 60 days before evacuating them to CONUS. 

When solid internal fixation was achieved, gentle active and passive flexion ex¬ 
tension exercises were instituted within a few days, postoperatively. Usually this re¬ 
sulted in a functional early motion of the knee, although late realignment of the 
bony architecture rarely produced a functional joint. 

To assess accurately the results of treating war injuries of the knee joint, one 
would need to follow the injuries from initial treatment to final disposition. However, 
in the Vietnam conflict, many men with minor wounds were treated in-country or at 
offshore hospitals and later returned to duty. Others succumbed to associated in¬ 
juries. Since accurate data of this nature are not available, the results of treating a se¬ 
ries of knee joint patients received at one general hospital are presented below. All of 
these patients were followed to a final disposition. However, one must keep in mind 
that this is a skewed series, representing primarily the more serious joint wounds. 

From January 1968 through December 1970,70 patients with knee wounds incurred 
in Vietnam were treated at Fitzsimons General Hospital (table 6). Twenty-eight injuries 
were caused by gunshot wounds, 38 wounds by fragments, and 4 puncture wounds by 


114 


ORTHOPEDIC SURGERY IN VIETNAM 


punji sticks. Ten patients had infected knees at the time of admission to Fitzsimons. Of 
the total of 70 patients, 52 (74 percent) were returned to active duty and 18 (26 percent) 
were discharged because of residuals from the knee injury. At the time of final disposi¬ 
tion, 56 (80 percent) of the knees had from 90 to 130 degrees of motion, 10 (14 percent) 
had from 60 to 90 degrees, and 4 (6 percent) had less than 60 degrees. 

As would be expected, the knees that had sustained intra-articular fractures did 
not fare as well as those that did not (table 7). Twenty-eight (40 percent) knees had 
sustained major intra-articular damage varying from total disruption of the articu¬ 
lar surfaces to a furrow plowed through one of the surfaces by the wounding device. 
Twenty of the fractures were caused by gunshot wounds and 8 by metal fragments. 
Fifteen (54 percent) of the patients returned to duty and 13 (46 percent) were dis¬ 
charged because of knee function impairment. Because of the greater velocity of 
the missile, the gunshot wounds generally caused greater disruption of the joint 
and, therefore, more serious impairment. Fifty percent of the patients with intra-ar¬ 
ticular fractures secondary to gunshot wounds and 37 percent of those with intra-ar¬ 
ticular fractures caused by metal fragments were disabled at discharge. The 28 cases 
with intra-articular fractures accounted for 13 of the 18 discharged related to knee 
residual impairment. In 3 of the remaining 5 cases, the disability was secondary to 
ligamentous instability, and 2 had marked limitation of motion from infection. 

The actual number of knee joint wounds that eventually became infected is not 
available, but to most orthopedic surgeons who served in Vietnam, PACOM, and 
CONUS hospitals, it appeared that this was not a common complication. The knee 
wounds that were recognized as infected at the time of reexploration for delayed 
primary closure were further debrided, irrigated, and left open for reinspection 3 to 
5 days later. If the wound appeared clean at that time, it was closed, systemic antibi¬ 
otics were continued for 14 to 21 days, and, where applicable, an active range of 
motion was started in 10 to 14 days. 

In the presence of continued infection, one of two courses was followed. One 
approach called for immobilizing the extremity in extension, leaving the wound 
open to drain, and administering appropriate systemic antibiotics until the infection 
appeared quiescent. After this had been achieved, wound closure was again at¬ 
tempted by whatever method necessary, most often by a split-thickness skin graft. 
When the joint appeared quiescent, motion was instituted. Where infection or the 
initial wounding agent had destroyed the joint, subsequent surgery was done to se¬ 
cure a solid bony ankylosis, which was commonly accomplished with a Charnley- 
type compression device (Charnley and Lowe 1958). This system allowed early am¬ 
bulation during fusion. At one CONUS hospital, for 9 patients with destroyed knee 
joints, surgeons attempted to secure bony ankylosis with compression clamps and 
plaster immobilization without surgical excision of the remaining cartilage and sub¬ 
chondral bone. This goal was achieved in only 1 case. The other 8 had residual mo¬ 
tion of the joint after removal of the clamps (Bailey and Burkhalter 1971). 

The second approach involved a modified Willems' regimen (Ballard et al. 1975). 
This method used wide arthrotomy, usually employing both medial and lateral para¬ 
patellar incisions because in several early cases where only the medial incision was 
used, lateral subluxation of the patella occurred. Through these incisions, the joint 
was thoroughly inspected and debrided of loose tissue fragments and other debris. 
Careful attention was paid to the synovium as it was incised. Purulent material exud- 


WOUNDS OF JOINTS 


115 


ing from its cut edges indicated abscess formation within the structure, making syn¬ 
ovectomy necessary. Synovectomy was also carried out if the synovium encroached 
upon the articular surfaces or in any way blocked joint motion. To complete the syn¬ 
ovectomy, the incisions were extended proximally along the interior edges of the 
vastus medialis and lateralis muscles. This provided access to all but the most poste¬ 
rior portion of the synovial tissue, which usually was left behind. The menisci were 
not excised unless severely damaged by the initial trauma or subsequent infection. 
The infrapatellar fat pad was not excised unless obviously grossly infected. 


Table 6.— Final disposition of patients with knee wounds 


Number 

Returned 

Wounding device Knees Percent to duty Percent Discharged Percent 

Gunshot. 28 40 18 65 10 35 

Fragments. 38 54 30 79 8 21 

Punji stick. 4 6 4 100 0 0 

Total. 70 100 52 74 18 26 


Table 7.— In fluence of intra-articular fractures on final results 
Cases with Intra-articular Fractures 


Number 

Discharged 

Returned with 

Wounding device Knees Percent to duty Percent disability Percent Infected Percent 


Gunshot. 20 71 10 50 10 50 2 10 

Fragments. 8 21 5 63 3 37 1 12 

Total. 28 40 15 54 13 46 3 11 


Cases without Intra-articular Fractures 


Gunshot . . . .. 8 — 8 100 0 — 0 

Fragments. 30 — 25 83 5 17 1 3 

Punji stick. 4 — 4 100 0 — 0 — 


Total. 42 — 37 88 5 12 1 


After the knee had been reexplored and a culture obtained both from the syn¬ 
ovial fluid and a macerated fragment of synovium, a broad-spectrum antibiotic was 
given, intravenously, throughout the remainder of the surgery and thereafter for at 
least 48 hours. Oral antibiotics were then given until the erythrocyte sedimentation 
rate had returned to normal. Organisms identified in the cultures determined the 
antibiotics prescribed. Antibiotics were adjusted according to the results of periodic 
cultures of the effluent joint fluid throughout the remainder of the postoperative 
course. Usually the antibiotics were discontinued in 3 to 4 weeks (fig. 36). 


























116 


ORTHOPEDIC SURGERY IN VIETNAM 







WOUNDS OF JOINTS 


117 



Figure 36. —Infection following penetrating in¬ 
juries of the knee without significant fractures 
were best treated by active motion in the pres¬ 
ence of an open wound. Without effusion there 
was little deterrent to considerable range of 
motion. Secondary wound healing was allowed. 









118 


ORTHOPEDIC SURGERY IN VIETNAM 


After surgical debridement, the wounds were left open on both sides. Fine mesh 
gauze was placed over the incisions, followed by a bulky pressure dressing, and the in¬ 
jured extremity was kept elevated continuously for 12 hours. Next, the bulky dressing 
was replaced by a smaller absorptive dressing to allow knee motion. Active-assistive ex¬ 
ercises of the knee were then carried out with the patient standing at the bedside. Pa¬ 
tients with stable intra-articular fractures were encouraged to ambulate on crutches 
with partial weightbearing. Unless this was done, the posterior aspect of the knee would 
act as a sump for the purulence in the knee. During his ambulation, the patient was re¬ 
quired to use active knee motion. This program necessitated close supervision of the 
patient's activity until he had obtained 70 degrees of flexion, which normally occurred 
within the first week. If this amount of flexion had not been achieved in 7 days, the knee 
was manipulated under anesthesia, and the regimen of knee motion was reinstituted. 

Wounds were allowed to close by granulation. This usually took 4 to 6 weeks but 
in some instances it required more than 4 months. Normally the wounds closed in 
from both ends. A small fistula remained, most frequently on the medial side of the 
knee. Eventually this fistula was closed. Irrigation, chemical debridement, antibi¬ 
otic installation, application of drains or wicks, or attempts at early closure were not 
done in wounds treated by this method. 

Thirty-four adult patients with pyogenic arthritis of the knee were treated at sev¬ 
eral medical facilities by this modified Willems' regimen from 1967 to 1972. Nineteen 
of these cases were secondary to open wounds of the joint sustained in combat, 8 
were postoperative infections, and 7 were hematogenous pyogenic arthritis. Staphy¬ 
lococcus aureus was cultured from 26 knees. Staphylococcus epidermidis from 4 
knees. Pseudomonas aeruginosa from 2 knees, and Neisseria gonorrhoeae from 2 
knees. The infection was eradicated in all 34 patients, with no recurrences during the 
follow-up period. A subtotal synovectomy was done in 14 of the patients in this series. 
This procedure was reserved for patients with severe synovial involvement, not nec¬ 
essarily those with the most damaged cartilage. The results were graded good, fair, or 
poor, according to the findings at the first recorded follow-up examination. 

A good result meant that the knee was asymptomatic, had more than 90 degrees 
of motion, and did not interfere with the patient’s activity. A fair result meant that 
the knee was only mildly painful, and had either 30 to 90 degrees of motion or 
caused some restriction of activity, or both. A poor result meant that there was 
more than mild pain in the knee and either less than 30 degrees of motion or the pa¬ 
tient's activity was markedly restricted, or both (Ballard et al. 1975). 

In 19 patients with open infected wounds sustained in combat, the results 
achieved were 7 good, 6 fair, and 6 poor. The 7 good results were in patients who had 
not sustained fractures in the joint or who had no major damage to the articular car¬ 
tilage from the wounding agent. Of the 6 patients with fair results in this group, 2 had 
fractures in the joint, 2 had moderate cartilage damage from the injury, 1 had a 
below knee amputation on the same side, and 1 had a below knee amputation on the 
contralateral side. Of the 6 patients who had poor results, 2 had surgical arthrodeses 
that resulted in solid bony fusion and a painless extremity, 2 had spontaneous anky¬ 
losis of the knee (1 bony and 1 fibrous—both resulting in a painless extremity), and 
the other 2 had residual motion of 20 degrees with intermittent pain on ambulation. 

Three of the 8 patients with postoperative knee infections obtained good results. 
The results of the other 5 were fair. A good result was achieved in 6 or 7 patients with 


WOUNDS OF JOINTS 


119 


hematogenous pyogenic arthritis. Pyogenic arthritis in the adult knee was not a serious 
threat to life or limb, but preservation of the joint remained a serious challenge to the 
treating physician (Jergesin and Jarvetz 1963). By using wide arthrotomies and early ac¬ 
tive motion of the knee joint, the joint could be more thoroughly evacuated of purulent 
material than when allowed to drain in an immobilized position, regardless of the num¬ 
ber of incisions. After the joint was still for a few hours, the first active flexion of the 
knee caused a large quantity of exudate to spurt from the wound. More fluid was evac¬ 
uated as the knee was subsequently put through its range of motion. As the knee was 
flexed actively, the quadriceps pressed on the suprapatellar pouch. In addition, with ac¬ 
tive extension, the posterior compartment was also compressed. In some cases, active 
motion caused dispersion of the infection, but when the knee joint was completely 
open, the fluid was evacuated rather than spread to the extra-articular tissues. In our 
patients, no sinus tracts developed and no contiguous osteomyelitis occurred (fig. 37). 

Joint infections started and spread in the synovial membrane and subsequently in¬ 
vaded the joint cavity. Therefore, it seemed logical to remove the infected tissue, if 
the involvement was extensive and beyond the ability of the host to eradicate the in¬ 
fection. before it destroyed the joint. Although Albertin. a French surgeon, first sug¬ 
gested the use of synovectomy for the treatment of pyogenic arthritis in 1896, little 
was reported subsequently about this procedure. Kelly and associates from the Mayo 
Clinic (1970) reported one case of an infected elbow' in which synovectomy was done, 
but only after ankylosis had occurred. This procedure seemed to be as worthwhile in 
fourteen patients with severe synovial involvement but with less than severe cartilage 
damage as it was when used for those with more severely involved joints. 

The fate of the articular cartilage exposed to prolonged suppuration was not 
predictable in this series of patients. Twenty-one of the 26 patients with Staphylo¬ 
coccus aureus infection were infected for more than seven days. Eight of these had 
a good result. The prolonged exposure of articular cartilage in a wound that re¬ 
mained open up to six months concerned us, since with our method of treatment— 
open arthrotomy and early active motion—the articular cartilage was frequently 
visible for several weeks, in one instance for three months. We had an opportunity 
to look at the articular cartilage after the infection had healed and the wound had 
closed in tw ; o patients who happened to require reconstruction of the patellar ten¬ 
don because of persistent laxity about two years after the episode of pyogenic 
arthritis. The cartilage appeared smooth and shiny with no gross erosion, but it was 
slightly thinned. A biopsy from the intercondylar area in one patient showed no mi¬ 
croscopic abnormalities. Although the eventual outcome of this treatment regimen 
cannot be ascertained, the early results appeared promising. 

WOUNDS OF THE HIP 

Open wounds of the hip joint constituted another major problem. Hip joint 
wounds were frequently associated with damage to the adjacent abdominal and 
pelvic contents or to nerves and vessels of the thigh. These wounds were always se¬ 
rious and carried with them a high rate of morbidity and mortality. 

The femoral head, because of its peculiar blood supply, leads a most precarious 
existence in the human body. When the femoral neck is severely fractured, axascular 


120 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 37.—This saggital diagram of a knee in partial flexion shows in orange the spaces 
that sequester effusion and purulent material. Active quadrups exercises, with anterior 
open wounds in the prone position, collapse the spaces and allow free drainage. 













WOUNDS OF JOINTS 


121 


necrosis of the femoral head occurs in almost all cases. When a high-velocity missile 
insults the head or neck and, at times, passes into the abdomen, contaminating the 
joint both from within and without the body, the chance of survival of that joint is nil. 

Although most orthopedic surgeons treating casualties during the Vietnam con¬ 
flict were familiar with multiple approaches to the hip joint, the precarious state of 
the patients who had sustained abdominal and vascular injuries frequently miti¬ 
gated against an initial thorough debridement of the hip. Abdominal and vascular 
injuries always took priority in the treatment plan. After abdominal exploration or 
vascular repair, the patient’s condition was frequently too poor to withstand a major 
surgical procedure on the hip. Despite this, if the eventual morbidity was to be re¬ 
duced, thorough debridement of the hip had to be carefully performed as soon as 
the patient was stabilized. Failure to do this was largely responsible for the high 
morbidity associated with hip joint wounds. 

Since accurate data for hip joint wounds in the Vietnam conflict were not available, 
this section is confined to recommendations for treatment of these wounds (Thompson 
and Omer 1954) and results obtained from records in one of the CONUS hospitals. 

Penetrating wounds involving the hip, pelvis, and lower abdomen were com¬ 
monly treated by combined teams of general, urologic, and orthopedic surgeons. In 
general, small bowel wounds were treated by appropriate debridement and closure. 
Colonic and rectal injuries were usually treated with exteriorization and open loop 
colostomies. When deemed essential to healing, presacral drainage was done 
through the presacral space and exited posteriorly through an opening created by a 
coccygectomy. In those cases involving penetrating wounds through the lateral 
bony pelvis or hip joint plus lower bowel, the bones and joints invariably became 
infected if this type of drainage was not provided (Christy 1972). 

All penetrating wounds of the hip joint required posterior arthrotomy and 
drainage, but exploration of the hip joint or ilium required the anterior approach 
for adequate exposure. The requirement of combined anteroposterior hip joint ap¬ 
proaches, therefore, necessitated placing the patient in a lateral position on the op¬ 
erating table. A Kirschner wire or Steinmann pin was placed through the proximal 
tibia so that the lower extremity could be suspended from overhead in a moderately 
abducted position. The pin was used for subsequent traction as well. The entire 
thigh, hip, hemitrunk, and thorax were shaved and washed with antiseptic deter¬ 
gent, and the lower extremity was drape-free. 

The anterior iliofemoral approach, extended proximally and posteriorly along 
the iliac crest as necessary, provided the best exposure to the hip joint, inner wall of 
the acetabulum, and both sides of the ilium. If possible, the existing wound of en¬ 
trance or exit was incorporated into this approach. If not, debridement was accom¬ 
plished separately, following the criteria of removing all possible contaminants and 
necrotic tissue. The hip joint capsule was opened with a “T” incision, the transverse 
portion of which paralleled the acetabular rim. All loose fragments of bone and car¬ 
tilage were removed from the joint. If the femoral-tractured neck had been tran¬ 
sected within the capsule and it was obvious that the blood supply to the temoral 
head had been destroyed, the free fragment of the femoral head and neck was ex¬ 
cised. Failure to do this at the primary debridement only ensured further infection 
and prolonged morbidity. The joint was copiously irrigated with saline to flush out 
clot and contaminants. If the posterior capsule had been penetrated, the damaged 


122 


ORTHOPEDIC SURGERY IN VIETNAM 


edges were excised. If the posterior capsule had not been penetrated, a window was 
created in this structure to allow for posterior drainage. When the wounding agent 
had penetrated the ilium or acetabulum, both inner and outer walls were debrided, 
preferably through the anterior approach. The necrotic muscle clothing both sides 
of the ilium was excised, and bone edges were rongeured or curetted to free them 
from contaminants. If it had been advisable to leave the femoral head in place, no 
internal fixation of the fracture was done at the initial debridement. 

If the incision had been extended to expose the anterior superior portion of the iliac 
crest, this portion of the wound was closed primarily, because retraction of the muscles 
made subsequent coverage of this portion of the ilium difficult or impossible. The re¬ 
mainder of the anterior incision, as well as wounds of entrance or exit, were left open. 
Posterior drainage was provided by a gluteal muscle-splitting incision. The sciatic nerve 
was identified and carefully protected during this approach. The gemellus and obtura¬ 
tor muscles were transected at their insertion into the greater trochanter and allowed to 
retract. A large catheter was placed adjacent to the posterior capsular opening and 
brought out through the gluteal muscle and skin incisions. Fine mesh gauze was placed 
over the wounds and covered by an occlusive dressing. A one-and-one-half hip spica 
cast was applied, and the tibial pin used for skeletal traction was incorporated in the 
cast. The cast was bivalved, and appropriate windows were made in the anterior por¬ 
tion to accommodate evaluation and care of abdominal or lower pelvic problems. 
These patients were normally kept in a hospital in Vietnam until the intra-abdominal 
injuries and repairs were sufficiently healed to allow safe air evacuation to a PACOM 
or CONUS hospital. Usually, this period ranged from ten to fourteen days after injury. 

Treatment at PACOM and CONUS hospitals consisted of removing the cast; in¬ 
specting the wounds under anesthesia in the operating room; redebridement when 
indicated by evidence of infection or residual necrotic tissue; and closing the anterior 
wounds if no infection was evident. Drains were removed from the posterior 
wounds. Usually, this site was allowed to heal by secondary intention. Granulating 
exit or entrance wounds that could not be closed with suture of local tissue were cov¬ 
ered with split-thickness skin grafts. Use of rotating skin flaps was generally avoided. 

Data are not available to allow accurate assessment of the treatment of hip joint 
wounds incurred in Vietnam, but the experience of one CONUS general hospital is 
probably representative of the overall results. Records are available for 19 patients 
with open wounds to the hip area admitted to Fitzsimons General Hospital from 
1967 to 1971. 

Open fracture of the acetabulum or ilium extending into the acetabulum was sus¬ 
tained by 7 of the 19 patients in this series. In only 1 of these was major damage done 
to the acetabulum. Five of these patients developed an infection that required 2 or 
more subsequent surgical procedures. Four of the 5 with infections had associated in- 
trapelvic or intra-abdominal injuries with bowel or bladder involvement. In 2 of these 
patients, the hip joint was eventually destroyed by the infection. The other 3 infec¬ 
tions resolved without major damage to the hip joints. Two of this group of patients 
sustained a complete lesion of a major nerve, 1 femoral and 1 sciatic. In neither case 
was repair at subsequent exploration feasible. Three of this group of patients were re¬ 
turned to duty, while 4 were medically retired from the service as unfit for active duty. 

Seven of the 19 patients had open extracapsular fractures of the proximal end of 
the femur. Six were comminuted intratrochanteric fractures, and 1 was at the base 


WOUNDS OF JOINTS 


123 


of the neck of the femur. Two of these patients developed infections that required 3 
or more subsequent surgical procedures. Three developed malunion of the fracture, 
which compromised gait and hip motion. One patient, with the basilar neck frac¬ 
ture, developed a nonunion requiring late internal fixation, but eventually healed 
with a good result. Two of this group had complete sciatic nerve injuries without re¬ 
turn of function after three years. One patient was a paraplegic secondary to frag¬ 
ment wounds of the spinal cord, another had a small bowel laceration, and a third 
later had a urethral transection. Of the group, 3 returned to duty with a limited duty 
profile, and 4 were medically retired. None of these patients suffered hip joint de¬ 
struction secondary to infection. 

Five of the 19 patients sustained open intracapsular fractures of the femur, but the 
femoral head was not excised at the initial debridement in any of these cases. All 5 
developed avascular necrosis of the femoral head. Four of the 5 had prolonged infec¬ 
tions that resolved only after removal of the dead infected head. Although the fifth 
patient did not develop an infection of the hip joint, the femoral head was removed 
because of avascular necrosis. Two of these patients sustained injuries to the sciatic 
nerve, 1 completed and 1 with peroneal involvement only. Neither of the nerve le¬ 
sions resolved. The infection in 3 of the 4 cases cleared after removal of the femoral 
head and debridement of the joint. The other patient required 3 subsequent opera¬ 
tive debridements before the infection finally resolved. In 4 of these cases. Ring 
metallic prostheses were used to reconstruct the joint three to twelve months after 
the infection had resolved clinically and radiographically. In the fifth case, a custom- 
built all-metallic femoral head neck and metallic acetabulum replaced essentially the 
entire top end of the femur as well as the destroyed acetabulum. In 3 cases, the Ring 
prosthesis loosened within two years of emplacement, resulting in pain and joint dys¬ 
function. In each of these cases, the Ring prosthesis was removed and replaced with a 
metal-plastic prosthesis cemented to the femur and acetabulum. At the time of the 
second reconstructive procedure, cultures from the hip joint were negative for growth 
in all instances. These patients were followed from three to five years, and in no case 
was a subsequent infection of the joint found. All patients retained an excellent range 
of motion in a relatively painless joint. None required or used external support for 
ambulation. All 5 of these patients were medically retired from active duty. This 
method of reconstruction was not standard. Time will determine whether it should be 
considered a feasible alternative to joint resection or arthrodesis in the young active 
person with a destroyed hip joint secondary to an open combat injury. 


WOUNDS OF THE SHOULDER 

Open injuries of the shoulder and upper arm were associated with a high incidence 
of neurovascular damage, which frequently proved to be the most disabling factor in 
the patient’s injury. In addition, head, neck, and chest wounds were commonly associ¬ 
ated with combat wounds of the shoulder joint. The care ol these associated lite- 
threatening injuries always took priority over the treatment ol the shoulder joint 
wounds. Tandem treatment teams cared for these multiple injuries, with the appropri¬ 
ate neurologic, vascular, thoracic, or general surgeon first taking care ol the other in¬ 
juries that did not involve the extremities. The orthopedic surgeon then debrided ex- 


124 


ORTHOPEDIC SURGERY IN VIETNAM 


tremity wounds, including those of the joints. Perhaps peculiar to the military surgeon 
of the Vietnam War was the custom of making the orthopedist responsible for the ini¬ 
tial, and frequently subsequent, treatment of the injured nerves in the extremities. 

Whether rendered in the field by a corpsman or in a hospital, the initial treat¬ 
ment of the shoulder wound resembled that of any other injury. Once in the operat¬ 
ing room, the surgeons addressed suspected injuries in order of priority. There, 
under general anesthesia, usually via endotracheal tube, the patient was positioned 
in a lateral or semilateral position; the shoulder girdle, neck, hemithorax, and upper 
limb were washed with an appropriate antiseptic solution; and a sterile drape was 
applied, with the upper extremity drape-free. An effort was made to pack the 
wound with a sterile sponge during the surgical preparation of the area to prevent 
further contamination as the remainder of the extremity and adjacent parts were 
cleansed. Anatomic anterior or posterior or both approaches incorporated the 
wound, where possible, into the incision. If neurological or major vascular struc¬ 
tures had been damaged, the nerves and vessels were first identified in an area re¬ 
mote from the wound and then traced to the site of damage. This prevented inad¬ 
vertent further damage during the surgical exploration. When the brachial plexus 
or subclavian vessels had been damaged by the traversing missile, resection of por¬ 
tions of the clavicle was sometimes necessary to gain access to these structures. 

The principles of debridement emphasized in other sections of this book were 
followed in treating shoulder wounds. A minimal amount of damaged skin was re¬ 
moved. Fascia, because of its poor blood supply and potential source of infection, 
was liberally excised and incised to gain exposure to the deep structures. However, 
because muscle tissue was absolutely critical to future shoulder stability and mo¬ 
tion, the real key to successful debridement was surgical judgment of viability of 
shoulder muscle tissue. If necrotic muscle was left behind, it served as a perfect cul¬ 
ture medium for bacteria; yet overzealous excision of viable muscle reduced the po¬ 
tential for joint function, since the shoulder joint depends so extensively upon the 
rotator cuff for its stability and motion. 

The criteria of muscle viability—color, contractility, consistency, and capillary 
bleeding—all served as useful guidelines in the course of debridement, with muscle 
consistency the most dependable. Nonviable muscle rapidly lost its firm rubbery 
consistency and became mushy, friable, and readily fragmented when grasped with 
tissue forceps. 

Commonly the joint was exposed through the interval between the anterior del¬ 
toid and pectoralis major muscles. The conjoined tendons of the short head of the 
biceps, coracobrachialis, and pectoralis minor muscles were transected at the cora¬ 
coid process and retracted medially and distally to allow greater exposure of the 
joint and better protection of the musculocutaneous nerve. The tendon of the sub- 
scapularis muscle was incised and this muscle retracted medially to expose the un¬ 
derlying capsule, which was trimmed carefully to preserve as much substance as 
possible to assist in the future stability of the shoulder. All small loose fragments of 
bone and cartilage were excised, while larger bone fragments with soft tissue at¬ 
tachments were carefully cleansed of visible contaminants and preserved. If the 
humeral head was completely devoid of soft tissue attachment and was lying as a 
loose free fragment in the joint, it was excised and discarded. Attempts to save this 
necrotic fragment of bone to aid in future reconstructive procedures were ill ad- 


WOUNDS OF JOINTS 


125 


vised. Such attempts frequently led to chronic infection of the joint, additional loss 
of bone substance, and further compromise of future reconstructive procedures. 

In perforating wounds, a separate posterior approach was required to complete 
the debridement. When possible, the incision incorporated the wound but, more im¬ 
portantly, anatomic approaches were followed so that undamaged tissue could be 
identified and protected. Access to the posterior shoulder was achieved by removing 
the posterior fibers of the deltoid from the spine of the scapula and incising the in¬ 
fraspinatus and teres minor tendons from the greater tuberosity of the humerus. 
Whenever possible, the supraspinatus tendon was left intact, since it is probably the 
most important member of the rotator cuff in providing shoulder stability during ac¬ 
tive motion of this joint. After surgical trimming of the contaminated and necrotic 
tissues, the joint was left open and dressed with fine mesh gauze placed loosely over 
the wounds. A bulky absorptive dressing was applied, and the limb was secured to 
the body with a Velpeau-type soft dressing, reinforced for transportation with a plas¬ 
ter cast. The cast was usually suspended from the opposite shoulder, which con¬ 
tributed to the comfort of the patient. Internal fixation of fractures was not done 
during this initial stage of wound care. Early in the conflict it was found that drains 
were not a good substitute for leaving the wound open, and their use was con¬ 
demned by members of the CINCPAC surgical conference in 1967 (CINCPAC-1 
1967). Rather than facilitating drainage, they actually blocked the egress of fluid 
from the depths of the wound, inviting further infection and tissue destruction. 

Patients with shoulder wounds and without other serious injuries were evacuated to 
an offshore hospital two to three days after the initial debridement. Those with compli¬ 
cating head, neck, chest, or abdominal injuries were retained in the initial hospital for 
observation for an additional seven to ten days. Since shoulder wounds were associated 
with significant blood loss that rendered the patient quite incapable of withstanding a 
prolonged airplane ride sitting comfortably or safely, patients with significant shoulder 
wounds were usually transported through the evacuation system on a litter. 

At five to seven days after initial wound debridement, the patient was returned to 
the operating room, the dressings were removed, and the wounds were inspected 
under general anesthesia. Further necessary debridement was then carried out. If the 
wounds appeared clean at this second-look procedure, the joint was closed, tendons 
were reattached where possible, and a delayed primary closure of the skin was done. 
When, because of tissue loss, skin closure was not possible, split-thickness skin grafts 
were used or the wound was left open to heal by secondary intention. Pedicle or local 
rotation flaps were rarely used, except for cases where coverage of nerves or major 
vessels was necessary. If the wounds were clean, appropriate internal fixation devices 
were used to stabilize major fracture fragments at this second-look procedure. 

Early motion of the shoulder was encouraged in all instances where future joint 
function was considered to be feasible and the stability of the fracture fragments 
was such that this could be done. This motion was commonly initiated at seven to 
ten days after the second-look procedure. A collar and cuff sling provided part of 
the support for the upper extremity. With the sling in place, the patient bent for¬ 
ward from the waist, allowing the arm to hang perpendicular tiom the tiunk, and 
with the assistance of a physical therapist, he put the arm through an increasing 
range of abduction, flexion, extension, and circumduction. Perhaps because ot the 


126 


ORTHOPEDIC SURGERY IN VIETNAM 


extensive scarring of the accompanying open wounds of the shoulder, surprisingly 
few of these patients developed subsequent problems with recurrent dislocations. 

When sepsis of the joint was suspected, the patient was returned to the operating 
room as many times as necessary for further cleansing of the joint and to ensure ade¬ 
quate drainage. The infected wound was left open, and active motion was encouraged to 
assist in the evacuation of the collected fluid from the joint. Systemic antibiotics were 
continued until clinical evidence of sepsis was no longer present, and frequently until the 
erythrocyte sedimentation rate had returned to normal. From 1967 to 1969, surgeons 
also attempted to prevent or control wound infection of many areas, including the shoul¬ 
der joint, by instilling local antibiotics through a suction irrigation system. A solution of 
1,000 units per ml. bacitracin, 1 percent neomycin, and 0.1 percent polymixin B was in¬ 
stilled by constant drip into the joint and evacuated either continuously or periodically, 
with a suction machine. Although this regimen was sometimes efficacious in controlling 
local infection, it carried with it considerable risk of systemic toxicity, especially in 
wounds such as the shoulder joint, where large areas of muscle tissue were bathed by the 
solution and absorbed it into the bloodstream. A number of cases of partial nephro- and 
ototoxicity were attributed to this treatment method. Therefore, in January 1968, Col. 
Thomas Whelan, surgical consultant to CINCPAC, distributed a communique to all hos¬ 
pitals in PACOM advising discontinuance of this method of treatment. 

In the patients with total destruction of the humeral head or glenoid or both, the 
limited available ways to handle the problem were resection arthroplasty, shoulder 
fusion, and prosthetic replacement of the upper portion of the humerus. The pros¬ 
thetic replacements were rarely applicable to the treatment of combat wounds of the 
shoulder. They depended upon the reconstruction of the rotator cuff for their stabil¬ 
ity, and this structure had usually become so scarred and contracted by the time the 
shoulder was ready for reconstruction that prosthetic replacements could not be used. 

Partial resection arthroplasty of the shoulder was the most common treatment 
method during the patient’s initial hospitalization. This procedure provided for 
some motion but was frequently associated with residual pain and weakness that 
precluded heavy lifting or other vigorous use of the upper extremity. However, be¬ 
cause of the heavy workload at the military hospitals and the desire of many pa¬ 
tients to leave the hospital at the earliest possible date, many with severely dam¬ 
aged shoulders were discharged after their partial resection arthroplasty. A better 
functional result could probably have been achieved by a shoulder arthrodesis. 

Shoulder arthrodesis was considered the most effective way of treating patients with 
severely damaged shoulder joints. Multiple methods of achieving this goal were used. 
Most incorporated three steps. First, all remaining cartilage was excised from both sides 
of the joint. Second, the humerus was securely fixed to the remaining scapula with 
metallic devices. Finally, an extra-articular bone graft was frequently added by placing 
the outer end of the osteotomized acromion into the remaining top end of the humerus 
or by a method preferred by a number of surgeons, the modified Brittain posterior 
scapulohumeral arthrodesis, in which a bone graft was inserted between the humerus 
and the scapula. Brittain (1952, 168-76) used an arrow-shaped tibial graft inserted into 
the humerus and notched to straddle the axillary border of the scapula. He recom¬ 
mended arthrodesis of the shoulder in 80 degrees of abduction, 30 degrees of internal 
rotation, and 40 degrees of forward flexion. This standard salute position was also rec¬ 
ommended by the research committee of the American Orthopedic Association in 


WOUNDS OF JOINTS 


127 


1942. It was used extensively in the treatment of flail shoulders secondary to birth in¬ 
juries and poliomyelitis in children and was usually quite satisfactory for these condi¬ 
tions (Barr et al. 1942). This position, however, was not without difficulty in the adult, as 
has been pointed out by Rowe (1974) and Davis and Cottrell (1962). The excessive ab¬ 
duction and forward flexion resulted in winging of the scapula, a prominent medial bor¬ 
der of the scapula, chronic stain of the scapulothoracic muscles, and neck pain. 

The shoulder arthrodesis method preferred by the surgeons at Fitzsimons Gen¬ 
eral Hospital used a tricortical iliac graft fashioned to fit in the arc formed by the 
humeral metaphvsis. lower edge of the glenoid, and the adjacent area of the scapula. 
This procedure was done through the posterior approach described by Kocher 
(1911. 1:322-23). The shorter iliac graft was made possible by the different position 
in which the shoulder wa's fused. The most satisfactory shoulder arthrodesis position 
in the adult was to abduct the arm to 20 to 30 degrees from the side of the body, for¬ 
ward flexed 30 degrees, and internally rotated 40 degrees. From this position the pa¬ 
tient was able to reach his hand to his face by scapulothoracic motion and elbow 
flexion. He could also reach his hip area without difficulty. From this position, the 
patient was also able to do heavy work that could not be done from the abducted po¬ 
sition. which depends upon the scapulothoracic muscles for its maintenance (fig. 38). 

Despite the known advantages of shoulder arthrodesis over shoulder resection, 
which allowed only limited motion frequently associated with pain, few shoulder 
arthrodeses were done on Vietnam patients during their hospitalization for initial 
wound care. Probably, the surgeons did not urge for this procedure because of their 
already high workload and the patient's usual desire to leave the hospital as soon as 
possible. Whether subsequent arthrodeses were done in these patients at other fa¬ 
cilities cannot be ascertained. 

From records available at Fitzsimons General Hospital, it is possible to glean 
some information on the history of shoulder wounds. Undoubtedly these cases rep¬ 
resent a skewed series, including those patients with severe wounds of the shoulder 
as well as the complicating associated injuries. For 40 of these patients, sufficient 
records were available to assess the results of their shoulder wounds and subse¬ 
quent treatment. All of these were young men between nineteen and twenty-five 
years old. Twentv-three had sustained gunshot wounds in the shoulder region. The 
remaining 17 shoulder wounds were secondary to metallic fragments from explo¬ 
sive devices. Nine patients had no injury other than that of the shoulder joint: the 
other 31 had associated injuries. Some patients had wounds in multiple other areas: 

Ipsilateral upper extremity nerves. 1- 

Contralateral upper extremity nerves. 1 

Chest. 1- 

Neck. 

Upper extremity (ipsilateral). 

Upper extremity (contralateral). - 

Brachial artery'. 

Head. 

Thigh. 6 _ 

Leg. ^ 













128 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 38.—Arthrodesis of the shoulder is possible without a humeral head utilizing 
internal fixation and iliac graft on the compression side of the fusion between glenoid 
and humeral shaft. 


WOUNDS OF JOINTS 


129 


Of the 40 patients with shoulder wounds, 20 (50 percent) were returned to an 
active duty status with a functional shoulder. The other 20 patients were discharged 
unfit for duty. Nine patients were unfit because of shoulder dysfunction secondary 
to bony or soft tissue injury about the shoulder, 8 were unfit due to residual com¬ 
promise of hand and forearm function caused by associated nerve injury, 1 patient 
had an above elbow amputation resulting from vascular injury, and the remaining 2 
had normal shoulders but residual osteomyelitis from their open tibial fractures. 

Two patients developed a shoulder wound infection that necessitated further 
surgical debridement. In both cases the wounds healed after the second surgery 
without residual osteomyelitis or further compromise of shoulder function. Both of 
these patients were returned to duty. Of the 9 patients with residual shoulder dys¬ 
function, 6 had sustained comminuted intra-articular fractures with loss of sub¬ 
stance of the joint, and the remaining 3 had lost the support of the soft tissue about 
the shoulder, resulting in a flail joint. Four of these patients had shoulder arthrode¬ 
ses, 2 during their initial hospitalization and the others within 2 years of discharge. 
Whether other patients discharged with residual shoulder dysfunction had subse¬ 
quent surgical procedures elsewhere is not known. 

Since the shoulder is a loose-fitting enarthrodial joint with a hemispherical 
humeral head rotating on a much smaller shallow glenoid fossa, it can absorb con¬ 
siderable damage and still retain its motion if its supporting muscle and capsular 
structures remain functional. The careful surgery done at all levels in the evacua¬ 
tion chain resulted in the surprisingly good results that were achieved during the 
Vietnam conflict. The infection rate was low, and the return to duty of even those 
who had sustained significant injury was quite high. The treatment of the severely 
damaged shoulder was by resection of loose unattached fragments, usually fol¬ 
lowed by institution of early motion. Residual painful or flail shoulders were 
treated subsequently by shoulder arthrodesis, frequently using a modification of 
the extra-articular arthrodesis described by Brittain (1952). 

REFERENCES 

Albertin,-. 1896. De la synovectomie et de l'arthrectomie dans les arthrites 

infectieuses aigues du genou consecutives aux plaies penetrantes de cette articu¬ 
lation. La Province Medicate , 1896: 195-97, 206-09. 

Bailey, J., and Burkhalter, W. E. 1971. “Failure to obtain knee fusion after severe 
injury to the knee joint. Unpublished manuscript. 

Ballard, A.: Burkhalter, W. E.; Mayfield, G. W.; Dehne, E.; and Brown, P. W. 1975. 
The functional treatment of pyogenic arthritis of the adult knee. J. Bone Joint 
Surg. (Am) 57,119-23. 

Barr, J. S.; Freiberg, J. A.; Colonna, P. C.; and Pemberton, P. A. 1942. A survey of 
end results on stabilization of the paralytic shoulder. Report on the Research 
Committee of the American Orthopedic Association. J. Bone Joint Surg. (Am) 
24:699-707. 

Brittain, H. A. 1952. Architectural principles in arthrodesis. 2d ed. Edinburgh: E. & 
S. Livingstone. 

Charnley, J., and Lowe, H. G. 1958. A study of the end-results of compression 
arthrodesis of the knee. J. Bone Joint Surg. (Br) 40: 633-35. 

Christy, J. P. 1972. Complications of combat casualties with combined injuries of bone 
and bowel—personal experience with nineteen patients. Surgery 71.270-74. 



130 


ORTHOPEDIC SURGERY IN VIETNAM 


CINCPAC-1. 1967. Commander in Chief, Pacific. First CINCPAC Conference on 
Surgery. Tri-service conference on war surgery conducted at John Hay Air Base, 
Philippines, 20-25 May 1967. 

CINCPAC-2. 1968. Commander in Chief, Pacific. Second CINCPAC Conference 
on War Surgery. Tri-service conference on war surgery conducted at John Hay 
Air Base, Philippines, 25-28 March 1968. 

CINCPAC-4. 1970. Commander in Chief, Pacific. Fourth CINCPAC Conference 
on War Surgery. Tri-service conference conducted on war surgery in Tokyo, 
Japan, 16-19 February 1970. 

CINCPAC-5. 1971. Commander in Chief, Pacific. Fifth CINCPAC Conference on 
War Surgery in Tokyo, Japan, 29 March-2 April 1971. 

Davis, G. L. 1970. Management of open wounds of joints during the Vietnam War. 
Clin. Orthop. 68:3-9. 

Davis, J. B., and Cottrell, G. W. 1962. A technique for shoulder arthrodesis. J. Bone 
Joint Surg. (Am) 44:657-61. 

DOD-EWS—Dept, of Defense, 1958. 

Feagin, J. 1966. The treatment of penetrating injuries of the knee joint with signifi¬ 
cant tissue destruction. Unpublished report. Headquarters, 85th Evacuation 
Hospital, 4 Nov 1966. 

Hampton, O. P, Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Opera¬ 
tions. Office of The Surgeon General, Department of the Army. Washington: GPO. 

Jergesin, F., and Javetz, E. 1963. Pyogenic infections in orthopedic surgery. Am. J. 
Surg. 106:152-62. 

Kelly, P. J.; Martin, W. J.; and Coventry, M. B. 1970. Bacterial (suppurative) arthritis 
in the adult. J. Bone Joint Surg. (Am) 52-4:1595-1602. 

Kocher, T. 1911. Textbook of operative surgery, vol. 1. New York: Macmillan Co. 

MD-WW—Medical Department, U.S. Army. The Medical Department of the 
United States Army in the world war, vol. 11, pt. 1. Washington: GPO. 

MSHWR—U.S. Surgeon General's Office. 1876. The medical and surgical history of 
the War of the Rebellion. Washington: GPO. 

NATO Emergency war surgery handbook. 1958. Department of Defense. Washing¬ 
ton: GPO. 

Rowe, C. R. 1974. Re-evaluation of the position of the arm in arthrodesis of the 
shoulder in the adult. J. Bone Joint Surg. (Am) 56:913-22. 

Thompson, M. S., and Omer, G. E., Jr. 1954. Gunshot wounds of the hip joint. Surg. 
Gynecol. Obstet. 98:237-40. 

Walton, S. 1970. Report of Orthopedic Consultant visit to Republic of Vietnam on 
3-15 April 1970 and to 5th Field Hospital, U.S. Army, Bangkok, Thailand, 
16-17 April 1970. 

Whelan, T. J., Jr. 1968. Ltr, Col. T. J. Whelan, Jr., to Lt. Col. Clyde N. Herrick, 31 
Jan 1968, sub: A Warning in the Use of Irrigation Aspiration Technique for Top¬ 
ical Neomycin, Bacitracin and Polymixin B Administration. 

Willems, C. 1919. Treatment of purulent arthritis by wide arthrotomy followed by 
immediate active mobilization. Surg. Gynecol. Obstet. 28:546-54. 


7 


Vietnam War Amputees 

Colonel Gerald W. Mayfield, MC, USA (Ret.) 


WOUNDS AND WOUNDING AGENTS 

Wounding agents during the Vietnam War differed from those in previous con¬ 
flicts. In World Wars I and II, and in Korea, artillery had been the greatest threat to 
the soldier. In World War II, land mines and shell fragments caused a majority of 
the wounds that resulted in amputation and were responsible for an increase to 5.3 
percent of troops suffering major amputations from the 2 percent from World War I 
(Cleveland and Shands 1970). Vietnam saw a significant shift in both the character¬ 
istics and the management of those wounds which caused the loss of a limb. The 
enemy had few heavy weapons, and, as a result, most casualties were caused by rifle 
and machine gun fires, mines, and booby traps. Such weapons had inherently 
greater destructive potential than shell fragments and made the proportion of limb- 
threatening wounds greater. Of these, mines and booby traps, weapons that ex¬ 
ploded at very close range, caused the greatest trauma and accounted for approxi¬ 
mately 55 percent of all amputations in one series. On the other hand, gunshot 
wounds caused only 8 percent of the amputations in the same series. 

Although the proportion of limb-threatening wounds was greater in the Vietnam 
War than in previous conflicts, rapid helicopter evacuation from the wounding site 
to a surgical facility that could resuscitate and treat all wounds expeditiously saved 
many apparently fatally wounded soldiers. Ironically, this success also dramatically 
increased the proportion of survivors with multiple amputations. Soldiers with more 
than one extremity amputated had accounted for 2 percent of the wounded in World 
War I and 5 percent in World War II. But during the Vietnam War multiple extrem¬ 
ity amputations rose to 19 percent in one series of 415 amputee patients and to 18 
percent in a longitudinal survey of 169 amputees. Many of these ablations were the 
result of inadequate vascular flow to the distal portion of the extremity. 

Even in cases of multiple system injuries, surgeons made every effort to save an ex¬ 
tremity. Many facets of the patient’s condition were considered before making the de¬ 
cision to amputate. Decisions were easy if the soldier arrived from the battlefield with 
a completely nonviable limb attached to the proximal segment by a few strands of tis¬ 
sue, or if there was complete absence of the distal portion. In contrast, decisions were 
difficult if the patient had a proximal wound with varying degrees of structural instabil¬ 
ity, tissue viability, infection, and altered states of nerve and vascular supply to the dis¬ 
tal part. American surgeons usually practiced a conservative approach to amputation, 
believing that the World War II experience demonstrated that reconstruction of 
severely injured extremities could be accomplished if surgeons provided proper initial 
debridement, meticulous wound care, and appropriate fracture management. 


132 


ORTHOPEDIC SURGERY IN VIETNAM 


In general, management paralleled guidelines listed in the NATO Handbook, 
Emergency War Surgery (1958). However, deviations inevitably evolved. These de¬ 
viations and their implications will be discussed in the following sections on man¬ 
agement of amputees in different regional zones of treatment. 

MANAGEMENT OF PATIENTS WITH AMPUTATIONS 

Treatment in Vietnam 

Complete information concerning the management of Vietnam War amputees 
in the United States Armed Forces, from the time of injury to some subsequent sta¬ 
ble point, is not available. The following narrative concerning amputee manage¬ 
ment is a composite of information gathered from published materials written by 
other orthopedic surgeons, a review of hospital records, and personal observations 
by surgeons from a number of medical facilities, including the 106th General Hos¬ 
pital in Yokohama, Japan; Valley Forge General Hospital in Pennsylvania; and 
Fitzsimons General Hospital, Denver, Colorado. 

Geographic factors, combined with fluctuating patient loads from changing tac¬ 
tical situations in Vietnam, had a direct effect on the continuity of optimum man¬ 
agement of the amputee. Most commonly a helicopter evacuated the patient from 
the battlefield to a hospital for evaluation of the extremity and wound assessment. 
If any distal portion of the extremity remained, the decision to amputate was made 
by or under the guidance of an orthopedic surgeon. 

. Subsequent to the amputation, the amputee was evacuated from Vietnam to a 
PACOM hospital within a few (three to ten) days. The time span depended on his 
general condition and the efficiency of the evacuation system. After an intermedi¬ 
ate stage of evaluation and treatment in a PACOM hospital, where the average stay 
was fourteen days, the patient was evacuated to CONUS. 

One of the most difficult decisions in the field of trauma surgery was whether to 
amputate an intact extremity with massive loss of bone, muscle, tendon, and nerve 
and with a compromised circulation. However, amputating at a preconceived 
“ideal” level was also discouraged. The ultimate course of treatment in the difficult- 
decision cases concerning amputation usually reflected, at least in the later stages of 
the evacuation chain, a joint patient-physician agreement. Amputation for life- 
threatening infections was performed occasionally. However, their incidence was 
lower in Vietnam than in previous conflicts. Amputation for established gas gan¬ 
grene was rarely required. Col. Raymond Bagg reported in 1977 that hyperbaric 
oxygen was used successfully to avoid amputation in two cases of clostridial my¬ 
ofascitis at the 106th General Hospital in Japan. 

Replantation of a sharply severed extremity was popular in civilian practice dur¬ 
ing the late 1960s and early 1970s, but replantation was apparently never attempted 
in the Vietnam War. Replantation may not be feasible even in future wars because 
ot the devastating effects of wounding agents, nonavailability of an appropriate 
team and facilities, and the potential necessity for rapid evacuation. 

In the Vietnam combat zone, open amputation was usually recommended. It 
was performed at the most distal point feasible, without regard to the “site of elec¬ 
tion. Surgeons emphasized debridement of all nonviable tissue and tried, if possi- 


VIETNAM WAR AMPUTEES 


133 


ble, to leave viable flaps. Frequently these flaps were irregular in contour and un¬ 
supported by underlying skeletal tissue. Appropriate support of these flaps with 
dressings and well-applied skin traction was necessary to preserve the viability of 
the flap. A notable exception was the failure of many primary Syme’s-type amputa¬ 
tions. because of necrosis of the heel pad portion of the stump. 

Some stumps were closed in Vietnam during the delayed primary closure period, 
extending from three to ten days after injury. Frequently, however, patients were 
evacuated from the combat zone before the operating surgeon knew whether the de¬ 
layed primary closure was satisfactory and whether the wound had healed without 
subsequent infection or flap necrosis. The operating surgeon had no official channel 
for follow up on the patient’s condition after he was evacuated from the combat zone. 

Blasting-type injuries from mines, booby traps, mortars, and grenades fre¬ 
quently caused deep penetrating wounds proximal to the level of amputation. 
Blasts beneath the person caused foreign material to penetrate vertically deep into 
thigh and buttock muscle and frequently to reach the knee and hip joints. Areas of 
deep contamination required additional longitudinal incisions on the extremity for 
adequate debridement. 

Control of arterial bleeding occasionally required other incisions proximal to 
the site of amputation. In above-knee amputations, open fractures of the ipsilateral 
femur required debridement stabilization by a plaster spica with skin traction to the 
stump. In the below-knee amputations with an associated femur fracture, skeletal 
traction with a tibial pin was accomplished. Before evacuation, a spica cast was ap¬ 
plied. incorporating the pin in the plaster. 

Immediate application and continuous use of skin traction on the open stump by 
methods described during World War II (MD-OSMTO 1957) were used, but not as 
extensively as they should have been. Wilber (1970) reported that, in Vietnam, only 44 
percent of 300 patients with open amputations were treated initially with skin traction. 
Only 50 percent of a group of orthopedic surgeons who cared for amputees at two or 
more echelons of evacuation indicated that adequate skin traction was applied or 
maintained during evacuation. Each of these surgeons, however, stated that he person¬ 
ally used skin traction in the initial treatment of the amputee, if it could be applied. 

The technique of applying skin traction is critical to its effective use. The NATO 
Handbook on Emergency War Surgery (1958) describes gluing stockinette to the 
distal 8 inches of the skin as a means of applying traction to the stump. Application 
of the adhesive material and subsequent traction to the skin proximal to a point 
only 2 inches from the end of the stump proved more successful, because it in¬ 
creased the efficiency of the traction on the most critical distal 2 inches of the stump 
and thus provided more rapid closure and tapering of the stump. 

To maintain effective skin traction through the healing phase, the weight and direc¬ 
tion of traction had to be kept constant and adjusted only by the physician. At the U.S. 
Army Hospital. Camp Zama, Japan, approximately 80 percent of the amputees arrived 
in 1969 with the skin traction ineffective. The weight bag was invariably resting on the 
evacuation litter. On questioning personnel involved in the transfer of the patients in 
the evacuation route, they replied that the patients had complained of pain, which was 
eased by relieving the tension of the swinging weight bag dangling over the litter pulley. 

In an effort to overcome the swinging weight problem, surgeons incorporated a wire 
ladder splint into a plaster spica for the above-knee amputee. For the below-knee am- 


134 


ORTHOPEDIC SURGERY IN VIETNAM 


putee, they provided an above-knee cast with traction applied by means of rubber tub¬ 
ing extending between the stockinette and a wire ladder splint. The major disadvan¬ 
tages of this method were difficulty in obtaining the materials necessary to apply the de¬ 
vice and, in some cases, having to alter the device to meet air evacuation requirements. 

A self-contained centrifugal pulley device, providing constant traction, was in¬ 
troduced to circumvent the problems of unknown tensions and balkiness on the 
wire-ladder-splint-rubber-band method. These devices never became widely used 
because they were seldom returned to the initial treatment area. Moreover, they 
were often found detached and not providing traction when the amputee arrived in 
the PACOM hospitals (fig. 39). 

Immediate Treatment in Offshore Hospitals 

Although a patient was occasionally kept in Vietnam for a longer period because 
of other associated injuries so severe that he could not be evacuated, the patient with 
a major amputation usually arrived in an offshore hospital within three to ten days 
after being wounded. The long flight to the offshore hospitals required multiple 
transfers that exhausted amputees, who also suffered varying degrees of dehydration 
and anemia as their bodies adjusted to the wound insult and subsequent surgery. 

Shortly after the patients arrival at the offshore hospital, efforts were made to 
correct any general medical and fluid problems. When his condition was stabilized 
adequately (usually within forty-eight hours), the amputation site was inspected 
under general anesthesia in the operating room. Frequently, redebridement was 
necessary to remove tissue that had declared itself nonviable since the original de¬ 
bridement. Proximal longitudinal incisions were sometimes necessary in both the 
below-knee and above-knee amputations for debridement of nonviable muscle 
from selective compartments in the extremity. The anterior compartment muscles 
of the short or intermediate length below-knee stump and the adductor muscle area 
in the above-knee amputee were most frequently found to be necrotic. 

After redebridement, skin traction was applied. If other injuries or medical con¬ 
ditions mitigated against early evacuation, skin traction was maintained by weights 
suspended over a pulley from the end of the bed. When the patient was likely to be 
evacuated in the immediate future because of abdominal, chest, other extremity, or 
other injuries, a self-contained traction apparatus was applied. 

A notable change in the management of the amputation wound at the offshore 
hospital evolved during the course of the war. In 1966, Dr. Oscar Hampton (1966) 
reinforced the concept of delayed primary closure of wounds, including amputation 
stumps. At the second CINCPAC Conference on War Surgery (CINCPAC-2 1968), 
the recommendation was made that an open amputation wound be regarded as “a 
major open war wound and that at the end of three to seven days, it [would] be par¬ 
tially closed with skin graft and the modified skin flaps... sutured in the most desir¬ 
able position without pinching." This advice, combined with other recommenda¬ 
tions throughout the conference (such as delayed primary closure at four to seven 
days), was interpreted by some in the offshore hospitals as an indicator that delayed 
primary closure should be performed on all amputation stumps, if possible. The fol- 


VIETNAM WAR AMPUTEES 


135 




Figure39— Continuous distal skin traction in open amputations prevents “shrinkage” 
of skin and stabilizes the soft tissue, increasing patient comfort. Self-contained contin¬ 
uous skin traction incorporated a wire ladder into a hip spica or long-leg cast. 






136 


ORTHOPEDIC SURGERY IN VIETNAM 


lowing paragraphs reveal some observations about the practices and results in care 
of the amputee in the offshore hospitals. 

In 1966 and 1967, at the hospital in Camp Zama, a number of delayed primary 
closures of selected amputation stumps were performed: Only stumps that had a 
“clean appearance, without gross necrosis, and were seen less than 10 days after am¬ 
putation” were closed. Closure was performed by or under the direct supervision of 
orthopedic surgeons only when no more than “light” tension was necessary at the 
suture line. These patients stayed at the Zama Hospital for an additional 10 to 14 
days to assure that no significant stump problems developed before evacuation. 

Although no specific recorded data are available concerning the outcome of this 
particular group of patients, it is our impression that the majority of these stumps 
remained closed, without debilitating wound breakdown. We expected and ob¬ 
served only minor suture reactions and localized areas of minor wound breakdown 
that did not require major operative intervention. 

Subsequent studies of longitudinal groups of patients treated at the 106th Gen¬ 
eral Hospital (Japan) and in CONUS revealed that both below-knee and above¬ 
knee stumps treated by delayed primary closure required significantly shorter time 
for fitting a final prosthesis than those treated by the open-wound method. This ob¬ 
servation may reflect a preselection of cases that were left open because of associ¬ 
ated injuries and, therefore, would be expected to take a longer period for healing. 

In an informal survey of orthopedic surgeons caring for amputations at different 
stages of evacuation throughout the war years, the majority indicated that the earli¬ 
est means of getting a closed stump which could be fitted with a prosthesis was by 
delayed primary closure. However, despite this excellent experience with delayed 
primary closure, this method presented difficulties in a forward zone, either in Viet¬ 
nam or offshore, because the operating surgeon was unable to follow the patient for 
an adequate length of time to determine if satisfactory healing occurred. On this 
basis, it was recommended, through verbal communication channels in 1968, that 
delayed primary closure not be performed unless the patient was assured of re¬ 
maining in the treating hospital for at least 14 days after closure. 

Conditions in CONUS 

Most amputees arriving in CONUS hospitals about 2 to 8 weeks following injury 
were in better physical condition and less fatigued than those patients arriving 3 to 5 
days after injury. Nevertheless, depending on the status of wounds, further examina¬ 
tion under anesthesia with redebridement was necessary in some patients. The extent 
of treatment leading to the point of definitive stump healing and prosthetic fitting 
varied considerably at different times at different institutions, based on many factors. 

Multiple amputees and thigh amputees derived a financial benefit by becoming 
medically retired as soon as their general condition was stabilized. Therefore, many 
of these amputees were not fitted with prostheses, but were discharged from Army 
Hospitals to Veterans Administration Hospitals with open wounds, making subse¬ 
quent follow up difficult. Large numbers of casualties at certain times of the war 
stimulated early medical boarding and transfer of amputees from CONUS active 
duty hospitals to Veterans Administration Hospitals. In some CONUS medical cen- 


VIETNAM WAR AMPUTEES 


137 


ters, it was teasible to award the patient a medical discharge from the service and, 
yet, to continue treating him as an inpatient under a medically retired status. Thus, 
continuity of care was not interrupted, and the patient continued the rehabilitation 
program and prosthetic fitting at one institution. 

In the course of the Vietnam War, no medical centers in CONUS were designated 
as "Amputee Centers,” with the possible exception of Valley Forge General Hospi¬ 
tal, which was given the authority on 1 February 1969 to establish an amputee service 
“to direct and supervise the care of all amputees in the hospital” (LaNoue 1971). 

In the majority of the hospitals, the amputees were not segregated onto a sepa¬ 
rate ward or into a specific “amputee service.” They were mixed with other ortho¬ 
pedic and trauma patients with a variety of orthopedic surgical diagnoses. In such a 
milieu, rehabilitation efforts were directed to the patient with multiple injuries, 
whether he was an amputee or whether he was otherwise injured. In treatment cen¬ 
ters other than Valley Forge, less formal arrangements were made in which one or 
more staff members concentrated their efforts on the overall management of the 
amputees. Due to the high volume of patients with amputations, who comprised 10 
percent of the orthopedic census at any one time, there appeared to be no difficulty 
in one amputee relating to another, although they were on a general trauma ward. 
The amputees usually benefited from this interaction with each other. 

MANAGEMENT OF AMPUTATIONS CLASSIFIED 
BY ANATOMICAL SITE 

Foot Amputations 

In managing foot amputations, surgeons strove to preserve all available skeletal 
and viable soft tissue length. Omer and Pomerantz (1972) stressed the preservation of 
as many segments of the foot as possible. [In a separate chapter of this volume Ballard 
also discusses amputations as related to other injuries of the foot.] Toe amputations, 
with the exception of the large toe, generally needed no special considerations. Am¬ 
putation of the large toe at the metatarsophalangeal joint interfered with running and 
fine balance adjustments, but did not present a major problem in ordinary ambula¬ 
tion. Transmetatarsal amputations were relatively infrequent in the Vietnam War and 
usually were maintained at the level of initial loss if sufficient skin flaps were present. 

The eventual functional results of amputation of the lateral two rays of a foot were 
usually good, allowing ambulation with a filler in the shoe. However, feet sustaining 
amputation of the entire first ray, particularly if any involvement of the second ray 
was present, usually had to be revised to a Syme’s amputation later because the re¬ 
maining lateral rays generally proved insufficient for painless efficient weightbearing. 

When traumatic amputations through the midtarsal area (Lisfranc) and through the 
midtarsal-tarsal joint (Chopart) occurred, usually insufficient skin remained to cover 
the terminal ends of these wounds. Small antipersonnel mines (“toe-poppers”) caused 
only partial injury to the bone and vascular structures, but destroyed the skin on the 
plantar aspect of the foot. These injuries were best treated by early Syme’s amputation, 
as the functional results of a skin-grafted plantar surface of the foot were usually poor. 
Such management was an exception and counter to the concept of retaining as much 
skeletal support as possible until secondary revisions could be accomplished. 


138 


ORTHOPEDIC SURGERY IN VIETNAM 


Experience at Fitzsimons General and in other CONUS hospitals indicates that 
the majority of patients who had Lisfranc or Chopart level amputations required 
later revision and amputation proximal to those sites. Muscle imbalances resulting 
from Lisfranc and Chopart amputations caused the remaining mid-foot and hind 
foot to go into progressive equinus and varus. If some of the ankle dorsiflexors and 
foot evertors remained or were reattached surgically or spontaneously the defor¬ 
mity could be avoided. Transfer of the posterior tibial tendon through the in¬ 
terosseous membrane to the dorsum of the remaining mid-foot was accomplished 
successfully in one patient at Fitzsimons General Hospital. This patient had a se¬ 
vere injury to the contralateral extremity, and it was desirable to maintain as much 
proprioceptive function in the foot amputation as possible. Weakening of the gas- 
trocnemius-soleus muscle group by early lengthening should be considered when 
equinovarus overpull is present. 

Prosthetic fitting of the transmetatarsal amputee usually required only a filler in the 
shoe. The coincidental development of a polypropylene foot-ankle orthosis in the civil¬ 
ian community during the Vietnam War allowed patients with Lisfranc and Chopart- 
level amputations to obtain more functional and less bulky fitting forefoot prostheses. 

The underlying causes of an extremely high failure rate of primary Syme’s amputa¬ 
tions performed at the initial treatment hospitals may never be known. However, some 
of the following facts should be considered. The surgical technique of Syme’s amputa¬ 
tions is exacting, particularly in the need to preserve an adequate blood supply to the 
plantar flap. A careful, unhurried dissection, based on exact knowledge of the anatomy, 
is necessary. It is possible that at least some of these amputations were performed by 
surgeons inexperienced in Syme’s amputations, or that mass casualty situations pre¬ 
vented some surgeons from spending the time necessary for a proper dissection. 

Another and probably more crucial factor in the survival of the flap was the 
method of stump stabilization after the operation. The Syme’s amputation flap 
could not be placed in a conventional circumferential skin traction apparatus. At 
the U.S. Army Hospital, Camp Zama, Japan, a number of patients with primary 
Syme’s amputation stumps arrived with necrotic flaps. These were apparently due 
to a dropping, posteriorly, of the unsupported plantar flap, causing an acute folding 
or torsion (or both) at the base of the flap that caused vascular compromise. The 
majority of the patients with Syme’s amputation stumps arrived in Japan without 
adequate stabilization by either external or internal means. A limited number ar¬ 
rived with either Kirschner wires or Steinmann pins traversing the flap into the dis¬ 
tal tibia. Although this method seemed to support the flap in proper anatomical re¬ 
lationships, in some cases, there was still some folding of the base of the flap and 
necrosis in the distal portion of the flap. 

The Vietnam experience suggests that a primary Syme’s amputation should not 
be performed as the initial debridement procedure, which should consist of remov¬ 
ing all obviously nonviable soft tissue and any skeletal elements of the foot that do 
not provide longitudinal length for the support of the remaining viable soft tissue. 
Later, when wound healing was stabilized, a secondary revision to a Syme’s amputa¬ 
tion could be accomplished with much less risk of loss of the plantar flap. Experi¬ 
ence at the 106th General Hospital confirmed that a large number of partial flap 
necroses occurred secondary to battlefield first-stage Syme’s. However, the major¬ 
ity of the patients in that series were still able to retain a Syme’s-length amputation 


VIETNAM WAR AMPUTEES 


139 


stump and were titted with a Syme’s prosthesis. This suggests that even though a 
partial flap necrosis occurred, a below-knee amputation was not necessary (fig. 40). 

During the Vietnam War, some important techniques evolved regarding secondary 
revision to a Syme’s amputation. To provide a good, stable end-bearing Syme’s stump 
and to avoid an unstable condition of the end pad, the extrinsic tendons were cut as 
high as possible and allowed to retract. The soft tissue pad was then stabilized by 
means of adhesive strapping and plaster external immobilization for six to eight 
weeks. To streamline the shape in some cases, the malleoli were shaved. This proce¬ 
dure allowed a better cosmetic prosthetic fit and, for best results, was done only after 
the Syme's stump was well vascularized and well healed, not at the initial amputation. 

Below-Knee Amputations 

In the majority of below-knee amputations performed during the Vietnam War, 
particularly toward the latter stages, an effort was made to preserve as much length 
as possible. Usually, the occasional primary closure and the more frequent delayed 
primary closure stump wounds healed completely or partially with some skin-edge 
necrosis and drainage, but some were total failures. The stumps that were surgically 
closed and then had to be opened for redebridement were usually treated with trac¬ 
tion and gradual closure with the aid of Steri-strip or skin grafts. 

The primary aim in the CONUS hospitals was to achieve a closed noninfected 
stump (without sacrificing functional length) that could be fitted with a prosthesis 
as soon as possible. Frequently, temporary plaster sockets with attached pylons 
were applied to both open and closed immature stumps. Fitting a prosthesis on a 
patient promoted his functional psychological rehabilitation. Emphasis was placed 
on ambulation, as soon as possible. Generally, prolonged bedrest and use of 
wheelchairs were discouraged. Early ambulation and mobilization appeared to en¬ 
hance the healing of associated lower extremity fractures. 

Varying methods and techniques were used at different times and in different 
centers to facilitate closure of the open below-knee amputation. Some of the meth¬ 
ods used at one time or another in treatment of below-knee amputees included: 
skin traction of either continuous or intermittent type until closure of wound; de¬ 
layed primary closure; secondary closure by revision; Steri-strip closure; a tempo¬ 
rary plaster socket to the open stump with attached pylon, and early ambulation 
until closure; either split-thickness or mesh-type skin grafts to the end or sides of 
the stump; and pedicle flap coverage of the stump. 

Medical records of amputees from Fitzsimons General Hospital and patients 
passing through the 106th General Hospital in Japan were evaluated to determine 
the efficacy of each of these methods. Retrospectively, it is difficult to determine 
the exact extent of skin traction effectiveness during the first several weeks after in¬ 
jury. This is because, in many cases, skin traction was not effectively maintained 
during the initial stage when it was most useful. Also, many patients had skin trac¬ 
tion at varying times in the course of treatment in combination with procedures 
such as secondary revision, Steri-strip closure, and skin grafting. 

In definitive-treatment CONUS centers, several different philosophies evolved 
concerning the revision of below-knee stumps to a “permanent definitive” stump. 


140 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 40.—A severe mid-tarsal gunshot wound was converted to a Chopart following 
debridement. When the foot was no longer reactive an elective Syme’s amputation was 
performed. 




VIETNAM WAR AMPUTEES 


141 


At some of the centers, the majority of amputations were treated with one of the 
methods until skin was essentially healed. Then, after a medical board, the patient 
was discharged from the hospital and transferred to a Veterans Administration 
Prosthetic Facility. Others used different management methods. At Fitzsimons 
General Hospital, the majority of below-knee amputees were fitted with “perma¬ 
nent” prostheses without revision to a “more permanent-type” stump. Most of 
these patients were able to tolerate a patella-tendon-bearing socket with soft end 
pad without revision of scars on the end of the stump. 

At Valley Forge General Hospital, emphasis was placed on performing more 
definitive type revisions to eliminate redundant soft tissue and adherent scar and to 
provide a more stable amputation stump. An Ertl-type revision, creating an os¬ 
teosynthesis between the distal tibia and fibula, was performed successfully in a 
number of cases (Deffer 1970; Moss 1970). Special prosthetic fitting was necessary 
to fit the shape of altered stump and to allow for the end weightbearing characteris¬ 
tics of this type of amputation. 

Several hospitals emphasized the use of temporary plaster sockets with attached 
pylon and foot to treat those amputees with immature stumps (fig. 41). This early 
weightbearing method, which also was used in World War II (Wilson 1969), rapidly 
decreased stump swelling in both open and closed stumps. At Fitzsimons General 
Hospital, a number of open amputation stumps were treated in this manner. The 
plaster sockets had to be changed every 3 to 5 days to accommodate the rapid 
shrinking of the stump, especially in the early phases of treatment. It was important 
to follow the detail of temporary plaster socket application as described by Burgess 
et al. (1969) to avoid breakdowns in normal skin areas due to poor fitting plaster. 

Occasionally, closed revision of a below-knee amputation stump with immedi¬ 
ate fit of a temporary plaster socket effectively controlled stump edema. However, 



Figure 41.—A temporary plaster below-knee 
prosthesis allowed ambulation and rapid stump 
shrinkage but required frequent cast changes. 





142 


ORTHOPEDIC SURGERY IN VIETNAM 


it was found detrimental to the closed incision site if the patient began full weight¬ 
bearing earlier than seven to ten days after the closed revision. 

Short below-knee amputation stumps (arbitrarily listed as less than four inches 
of tibial length) frequently were skin-grafted or allowed to close secondarily. An¬ 
other approach to the short below-knee amputation was the use of pedicle flaps to 
provide more durable skin surface for prosthetic fitting. To aid in future ambula¬ 
tion, preservation of the knee joint, even with a short stump sometimes measuring 
only 2.5 to 5.0 cm. (1 to 2 inches) it was desirable to provide proprioceptive feed¬ 
back and overall stump length. Anesthetic skin flaps did not present a problem in 
fitting the prosthesis or in its acceptance by the below-knee amputees (Keblish et 
al. 1970). Sometimes lack of skin about the knee joint meant revision of the short 
below-knee stump to an above-knee amputation rather than knee disarticulation. 

An ipsilateral fracture of the femur was a common complication. Twenty-one 
ipsilateral femur fractures associated with below-knee amputations were treated at 
Fitzsimons General Hospital and fourteen were recorded in a series at Valley Forge 
General Hospital (Herndon et al. 1973). Initially, the femur fracture reduction was 
maintained by means of a pin through the proximal tibia with balanced skeletal 
traction. After the patient reached one of the CONUS treatment facilities, a modi¬ 
fied cast brace was applied which incorporated the Steinmann pin in the cast brace. 
A pylon and solid ankle cushion heel (SACH) foot was attached. In some cases, the 
knee could be mobilized by appropriately placed knee hinges. 

Knee Disarticulation 

When it was apparent that a below-knee level amputation would not remove all 
nonviable tissue in the proximal part of the leg, a primary open-knee disarticulation 
was frequently performed. This level of extremity removal for debridement pur¬ 
poses could be rapidly performed with relatively little blood loss. It was alleged that 
the retained hyaline cartilage prohibited the proximal spread of infection, but this 
concept is questionable. Furthermore, skin grafts over this area took poorly, if at 
all, after the hyaline articular cartilage was exposed. Secondary closure by either re¬ 
vision at the same level or wound healing by secondary intention was unsuccessful. 
Early and continuous skin traction, combined with delayed closure by suture or 
Steri-strip, was effective in some cases. If closure had not been accomplished within 
approximately three to four weeks and hyaline articular cartilage decomposition 
was prominent, then an above-knee amputation had to be performed. 

Knee disarticulations had several disadvantages. First, there was poor cosmesis 
due to excess length when any type of hydraulic knee was fitted, and second, there 
was an inability to accommodate ischial weightbearing with the use of the total con¬ 
tact quadrilateral socket, due to the bulbous condyles at the end of the stump. 

Frequent breakage of outside hinges on a conventional knee disarticulation 
prosthesis also was a recognized disadvantage. The introduction of two new types 
of four-bar linkage polycentric knee joints in the late 1960s alleviated the cosmetic 
and hinge breakage disadvantages. With this new type of knee joint, the patient 
could sit with the knee flexed without undesirable excess length of the prosthesis. 


VIETNAM WAR AMPUTEES 


143 


At Oakland Naval Hospital, thirty-three patients with knee disarticulations un¬ 
derwent osteoplastic revision of the distal end of the stump, excising the prominent 
femoral condyles as described by Mazet and Hennesy (1966). This surgical modifi¬ 
cation of the stump allowed fitting of total contact quadrilateral suction sockets 
(Utterback and Rhobrer 1973). 


Above-Knee Amputations 

As much thigh length as possible was kept at the time of initial amputation in 
order to provide a biomechanically functional remnant and to obtain a closed 
stump. All methods described for the treatment of the below-knee amputee were 
applicable, in some form, to above-knee amputations. Frequently, the injuring 
agent also caused trunk, upper extremity, and contralateral extremity wounds, as 
well as the above-knee deficit. The number of bilateral above-knee and triple am¬ 
putee patients was significant. 

Early application and maintenance of skin traction was useful in closure of the 
open-circular type and equal-flap type amputations. Many of the above-knee 
stumps, however, had irregular flaps with large areas of skin loss and proximal 
wounds, all of which tended to negate the effects of conventionally applied skin 
traction. Split-thickness skin grafts, particularly the mesh type, were helpful in cov¬ 
ering these large irregular wounds, especially in the short above-knee stump. Steri- 
strip closure also played a part in decreasing wound size. 

In a number of instances the above-knee amputations were performed because 
a vascular repair failed at the site of a thigh wound that also included a fracture of 
the femoral shaft. In some cases, amputation was performed through the fracture 
site, thus removing a potentially useful distal segment of femur which could have 
been used ultimately to provide a longer stump and thereby improve the patient s 
ambulation. Another reason that amputation should not have been performed 
through the fracture site was that there was frequently a chance that the surround¬ 
ing soft tissues would support union of the femur fracture, which would result in a 
longer and more functional stump. 

At the time of secondary stump revision, a few surgeons performed myodesis or 
myoplasties to provide increased muscle control and proprioceptive feedback as 
advocated by Weisse, perhaps because identifying the muscles and reestablishing 
muscle length in these traumatic amputees were difficult. An important considera¬ 
tion in ultimate fitting of the above-knee amputee’s prosthesis was excess bulk, par¬ 
ticularly on the end of the amputation stump. This bulk caused relative instability 
of the femur within the above-knee prosthetic socket. Some amputees developed a 
painful bursa beneath the excess muscles as they rubbed across the bone end. 

Special problems occurred in the management of amputation wounds of the high 
thigh, hip disarticulation and hemiplevectory type. Contamination of the wounds by 
fecal material was prevalent, particularly in those amputees with high bilateral 
losses. A diverting colostomy was performed in many of these patients. This proce¬ 
dure significantly decreased wound contamination by fecal material. Skin traction 
could not be effectively applied to these areas by the usual methods. One method, 
utilizing wire sutures placed through the skin edges and attached to traction, was im- 


144 


ORTHOPEDIC SURGERY IN VIETNAM 


provised, but this technique could be used only for a short time, a few days at the 
most, before the wires would necrose the skin edges and pull out. 

Hand Amputations 

The upper extremity amputee presented a different challenge to the trauma sur¬ 
geon. While the lower extremity amputee needed a stable skeletal support, sur¬ 
rounded by mature, nonpainful soft tissues and durable skin which could tolerate 
both high friction and pressure loading, the upper extremity amputee needed to re¬ 
tain as much sensitivity as possible in the remaining part of the extremity. The un¬ 
trained, unilateral upper extremity amputee transferred many functions to the re¬ 
maining intact hand and seldom used the extremity with the amputation. Therefore, 
one of the major aims in management of the upper extremity amputee was to reduce 
the natural tendency for complete substitution of all functions to the intact hand. 

Initial treatment of the wound causing loss of the distal portion of the upper ex¬ 
tremity involved thorough debridement of any nonviable soft tissues. Every effort 
was made to maintain as much of the skeletal support as possible as well as to pre¬ 
serve skin for use in later reconstruction. After initial debridement and during sub¬ 
sequent stages of care, skin traction was applied. In many cases, this hastened clo¬ 
sure of the wound. Delayed primary closure and secondary closure by suture or 
skin graft were also used, as required, without shortening of the amputation stump. 

In general, utilizing these methods of care, the wounds of the upper extremity 
amputee healed more favorably than those wounds treated by the same methods in 
the lower extremity amputee (LaNone 1971). 

Wrist Disarticulation 

A wrist disarticulation was performed whenever there was an intact distal radius 
and ulna as well as sufficient skin flaps to cover the bone ends. This level of ampu¬ 
tation was considered more functional then a medium or long below-elbow ampu¬ 
tation. The expanded shape of the radius and ulna allowed for a more “rectangu¬ 
lar” configuration, providing a large stable contact area for the socket. 

There were, however, major disadvantages with this level of amputation. This 
long stump, when fitted with a prosthesis, had a total length as long or longer than 
the normal extremity. This added length had poor cosmetic qualities because it ac¬ 
centuated the presence of the prosthesis and amputation condition. It also precluded 
the use of a self-contained electronic terminal device. This “electric arm” needed 
space between the stump and terminal device to house the batteries and integrated 
electronic components. In one survey of amputee clinic chiefs, 56 percent preferred 
the long below-elbow amputation to a wrist disarticulation (Newsletter 1970). 

Below-Elbow Amputations 

The short below-elbow stump was preferable to an elbow disarticulation or an 
above-elbow amputation. Full thickness skin graft coverings were accomplished in 
a few cases to preserve this lower level of amputation, thereby preserving motion at 


VIETNAM WAR AMPUTEES 


145 


the elbow joint. Salvage of the short below-elbow amputation with pedicle flap skin 
coverage was achieved in some cases. Fitting by means of a Munster-type below- 
elbow socket made use of the preserved proprioception and elbow motion in these 
short below-elbow stumps (fig. 42). 


Figure 42. —The use of an elastomer foam in¬ 
sert allowed early prosthetic training while the 
stump was still reaching equilibrium. The 
foam insert could be changed frequently and 
acted as a stump “wrap.” 





















146 


ORTHOPEDIC SURGERY IN VIETNAM 


Rehabilitation for below-elbow amputees began with learning to use a tempo¬ 
rary training prosthesis. At Fitzsimons General Hospital, thirty-eight below-elbow 
amputees were treated with application of temporary upper extremity prosthetic 
training devices. Plaster sockets with attached terminal devices and appropriate 
harnessing allowed early functional rehabilitation and training to negate some of 
the tendency for the patient to become entirely “one-handed." At the same hospi¬ 
tal, an oversized laminated socket filled with Elastomer foam to make a custom fit 
for the stump was used as a temporary training arm while awaiting stump maturity 
and permanent prosthetic fitting (Burkhalter et al. 1976). 

Elbow Disarticulations and Above-Elbow Amputations 

Retaining the humerus in extremely short above-elbow amputees was advanta¬ 
geous because this benefited the shoulder joint contour cosmetically and provided 
some base for suspension of a prosthesis. As the upper extremity level became pro¬ 
gressively shortened, the patient acceptance rate became lower; however, six of 
nine shoulder disarticulation patients at Fitzsimons General Hospital were consid¬ 
ered prosthetic wearers one to two years after amputation (Burkhalter et al. 1976). 

A few patients with elbow disarticulations were fitted with prostheses that utilized 
the condyles of the humerus to aid in suspension. An additional advantage of disartic¬ 
ulation was better rotational control of the socket on the stump, provided by the 
prominent condyles of the humerus. Prosthetic fitting of external elbow joint hinges 
was necessary to avoid excess length. This was a minor disadvantage and, due to the 
relatively low stresses applied, breakage of the hinges was not a common problem. As 
much length as possible of the above-elbow stump was preserved and, frequently, to 
preserve the skeletal length, skin grafts were applied over open areas. These skin 
grafts were particularly useful in covering short above-elbow amputations. At Fitzsi¬ 
mons General Hospital, twenty-nine above-elbow amputees were fitted with tempo¬ 
rary training arms, and early functional use of the extremity was emphasized. This 
training arm was similar to the one described for the below-elbow amputee—an over¬ 
sized laminated plastic socket with an interposed Elastomer foam between the stump 
socket and the attached elbow-terminal device unit (Burkhalter et al. 1976). 

SPECIAL PROSTHETIC CONSIDERATIONS 

Responding to the need to place the lower extremity amputee in the upright walk¬ 
ing position to enable him to return to useful society as soon as possible, a number of 
special prosthetic devices were originated in the CONUS treatment centers. Tempo¬ 
rary plaster sockets with attached pylons and feet were used. In lieu of the temporary 
plaster socket and pylon, seventy-five below-knee amputees were fitted with bent- 
knee pylons at Fitzsimons General Hospital. These lightweight devices, constructed 
from aluminum crutches, featured a supporting platform and a pelvic band which al¬ 
lowed the amputee freedom from crutches. Thus, he could use his upper extremities 
for other activities (fig. 43). When below-knee amputees with flexion contractures 
used this device, their contractures decreased (Pinnell and Mayfield 1972). A similar 


VIETNAM WAR AMPUTEES 


147 



Figure 43. —The bent-knee pylon allowed 
early ambulation on a maturing stump with 
open wounds or skin grafts. 


stump-containing device with attached pylons, both articulated and nonarticulated, 
was attempted for the above-knee amputees but did not prove successful. 

The bilateral above-knee amputee presented a challenge throughout the reha¬ 
bilitation phase. To lower the center of gravity and to aid the balance of the am¬ 
putee, he was fitted with a “stubby” training prosthesis. The device allowed the pa¬ 
tient to get out of the wheelchair early and, frequently, to walk without crutches or 
canes on the first attempt (Brown 1970). 

Although stubby prosthesis permitted the bilateral above-knee amputee early 
ambulation and balance training, personal communications with some of these pa¬ 
tients indicated a negative psychological impact. The rather marked foreshortening 
was considered demeaning, though they realized this pair of “stubbies” was only a 
temporary mode in their rehabilitation cycle. Later at Fitzsimons General Hospital 
(February 1970 to October 1972), this problem was circumvented by fitting 17 bilat¬ 
eral above-knee amputees with early temporary plaster quadrilateral sockets and 
four-bar linkage polycentric nonhydraulic knee joints. These Polycadence knee 
units were extremely stable in stance phase and allowed the amputee to stand with 
normal length prosthetic devices. Frequently, he was able to ambulate with minimal 
assistance after several days (Mayfield and Burkhalter 1973; Mayfield 1971). 

The fitting of permanent prostheses at the centers that retained amputees until 
they could be fitted was influenced in part by the simultaneous development of 
prosthetic innovations in the civilian community. Cooperation with the Veterans 
Administration Prosthetics Research Unit allowed introduction of some of the 
newest developments in prosthetic research to the men who incurred amputations 
from wounds during the Vietnam War. 



148 


ORTHOPEDIC SURGERY IN VIETNAM 


For the Syme’s and knee disarticulation level amputees, sleeve-type slip-in inner 
sockets with suspension incorporated within the socket were available. Short 
below-knee amputees with poor distal skin surface were often fitted successfully 
with a variance of the patellar-tendon-bearing prosthesis. The total contact hard 
patellar-tendon-bearing socket was used extensively to fit the more mature below- 
knee stumps. A soft Silastic material endpad was used with a hard socket to accom¬ 
modate changes of the relatively immature stump. Some amputee clinics continued 
to use the patellar-tendon-bearing socket with a soft Kimbrough liner. 

In order to accommodate immature stumps that could be expected to change di¬ 
mensions rapidly, certain heat labile plastic substances, such as Polysar, were used 
to construct the sockets. Generally, however, these sockets were more time-con¬ 
suming to construct and more expensive than a temporary plaster socket. Attempts 
were made to fit mature stumps with more advanced socket designs, including air- 
cushion sockets and gel-lined sockets. Overall, these attempts were not as satisfac¬ 
tory as the more conventional patellar-tendon-bearing hard or soft sockets. 

Deffer (1970) described his experience with nearly one hundred Ertl osteoplas¬ 
ties. He emphasized that special prosthetic considerations were necessary to take 
advantage of the end weightbearing characteristics of this revised stump. Accurate 
fit of the below-knee prosthesis was evaluated by use of weightbearing x-rays ob¬ 
tained of the stump in the socket. Microcapsule pressure-sensitive sockets, as de¬ 
scribed by Brand and Ebner (1969), were utilized to detect abnormal prosthetic 
socket pressures on the skin of the stump. 

A radiographic technique was developed at Fitzsimons General Hospital to as¬ 
sess the socket fit and the relative adducted/abducted position of the hip joint on the 
amputation side. The x-rays were taken with the patient standing and with the heels 
two inches apart. It was found that the majority of protheses were fitted with the am¬ 
putee's hip in abduction and with poor stump support by the lateral wall of the 
socket. This alignment placed the hip abductor muscles at a disadvantage and glu¬ 
teus melius type of gait was present. This x-ray technique was utilized during the 
prosthetic fitting process to assure proper adduction position of the hip (fig. 44). 

The majority of above-knee amputees were fitted with prostheses containing ei¬ 
ther constant-friction single-axis knee joints or assorted swing-phase-control hy¬ 
draulic or pneumatic units. The Henche, Mauke S&S knee joint unit, which incorpo¬ 
rated a more stable stance phase mode, was fitted to both unilateral and bilateral 
above-knee amputees at Fitzsimons General Hospital and Walter Reed Army Medi¬ 
cal Center (Baker 1970). An amputee fitted with a prosthesis of this type of knee joint 
required special training before he could utilize all of the features properly. After 
1969, at Fitzsimons General Hospital, the majority of bilateral above-knee amputees 
were titted with four-bar linkage Polycadence knee joints, which provided stance 
phase stability and allowed the amputee to walk with only one cane. Four amputees 
were titted with a Polycadence knee on one side and a Henche, Mauke S&S knee in 
the opposite prosthesis. This was a favorable combination because the patient could 
use the S&S knee to aid in sitting and descending stairs while the Polycadence knee 
provided stance phase stability. A four-bar linkage, polycentric knee with a swing 
phase hydraulic cylinder was used in some prostheses in the latter stages of the Viet¬ 
nam War. This combination was used to the best advantage when fitted in those am¬ 
putees with knee disarticulations or long above-knee level amputations. 


VIETNAM WAR AMPUTEES 


149 



Figure 44. —X-ray evaluation of socket fit and 
position of the femur and hip joint in the 
socket improved fabrication of the prosthesis. 


LESSONS LEARNED 

Preservation of the major bony skeletal structures of the extremity at the most 
distal level possible is recommended to serve as a supporting strut for any viable 
soft tissue. This tissue is useful in later reconstructive stump revision even though 
the bone itself may not be preserved for the eventual amputation level. Conversion 
of the traumatic Lisfranc or Chopart level of foot amputation to a Syme’s amputa¬ 
tion at a later time is an example of this concept. 

Irregular stump configurations maintaining viable skin flaps and other soft tissue 
that can be used to cover critical skeletal elements proximally should be salvaged. Ini¬ 
tial circular amputation through a “site of election” should be avoided, particularly if 
variable skin flaps can be retained for use in reconstruction of a stump that saves a 
functioned joint. For example, with soft tissue flaps to cover a short skeletal segment 
of a below-knee stump, we could salvage the critical function of the knee joint. 

Exploding weapons, such as mines at ground level, frequently propelled foreign 
inorganic and organic material, as well as the amputee’s own bone fragments, deep 
into the proximal tissues. The only evident open wound was the traumatic amputa¬ 
tion, the more proximal skin remaining intact. If proximal trauma was not suspected 
and proximal debridement neglected these foreign elements and surrounding tissue, 
necrosis secondary to their high velocity passage was as source of deep infection and 
potential loss of limb at a level proximal to the traumatic amputation site. A high 
index of suspicion of this condition in all blast-type amputations was necessary, and 
adequate proximal longitudinal incisions, frequently the length of the proximal limb 
segment, were required to perform adequate debridement of the wound. Proximal 




150 


ORTHOPEDIC SURGERY IN VIETNAM 


swelling associated with contaminated traumatically dissected tissue planes at the 
amputation level, the “dirty envelope syndrome,” was a clue to pursue proximal dis¬ 
section along these planes. An x-ray of the proximal limb segment was a necessity 
and could reveal proximally driven stones, metal, or bone, or air in the soft tissue. 
The most common example of this occurrence was the blast injury-incurred below- 
the-knee amputation with contamination and necrosis of the adductor area of the 
thigh. Exploration of the knee or hip joints should be considered in all blast injury- 
incurred amputee patients if there is any suggestion of proximal contamination. 

Retention of the knee joint with intact muscles and nerves to provide motion 
and proprioceptive feedback in below-knee amputees promoted more stable gait 
patterns than were possible for above-knee or knee disarticulation amputees. An 
open circular amputation stump with only two inches of tibia should be retained 
with split-thickness skin grafts, secondary thickness pedicle flap coverage, or even¬ 
tual closure by secondary intention wound healing to complete the skin coverage. 

Statistics show that delayed primary closure of selected “clean” amputation 
stumps allowed the least time before prosthetic fit as compared with all other 
courses of wound management. Many factors contribute to the decision to perform 
a delayed primary closure of a traumatic amputation stump in a war zone environ¬ 
ment. The surgeon must have considerable experience in wound evaluation, partic¬ 
ularly in assessing tissue for contamination and viability. Adequate skin must be 
available to close the wound without tension at the suture line, and the operating 
surgeon must be able to evaluate the wound and patient’s response to delayed pri¬ 
mary closure for at least seven days postoperatively. If deep infection or tissue 
necrosis occurs, endangering either the patient’s life or eventual stump length, the 
surgeon must not hesitate to perform a “delayed primary opening” procedure and 
to remove all sutures in the stump. Then he must perform meticulous redebride¬ 
ment of the stump. A switch to an open method of skin traction and plaster dress¬ 
ings will then be necessary. 

Temporary plaster sockets with attached pylons and prosthetic feet were used 
successfully in CONUS hospitals. These allowed ambulation of the lower extremity 
amputee within a few weeks after amputation (Mayfield and Burkhalter 1972). The 
increased mobility of the amputee in an upright walking posture contributed signif¬ 
icantly to positive mental attitudes as compared to those amputees treated by the 
nonambulatory methods of continuous skin traction in bed. Ambulation also con¬ 
tributed to rapid stump shrinkage and maintenance of proximal muscle group tone 
and coordination. Maximum advantage of this ambulatory treatment was obtained 
by applying the temporary socket and pylon approximately ten to fourteen days 
after stump closure by delayed primary closure or secondary revision. In the inter¬ 
val between closure and pylon fitting a temporary nonweightbearing plaster dress¬ 
ing was used to immobilize soft tissue, to decrease pain and edema, and to protect 
against direct external forces (Mayfield and Burkhalter 1972). 

Open stumps that could not be closed safely or those that broke down after clo¬ 
sure were treated by immediate application of weightbearing socket and pylon after 
another thorough debridement. These stumps closed eventually by secondary in¬ 
tention. Meanwhile the patient was ambulatory and maintained the functional 
length of the salvaged longer stump. Relatively little pain was experienced by the 
amputee with an open stump ambulating in a socket-pylon. 


VIETNAM WAR AMPUTEES 


151 


After surgery on the upper extremity amputation stump, the patient was imme¬ 
diately fitted with a temporary plaster socket or an oversized laminated socket 
filled with Silastic foam and an appropriate terminal device with harness attached. 
This permitted early prosthetic training and return to functional activities. When 
early functional use of the extremity was obtained by this method, phantom pain 
syndrome was reduced. 

Observations were repeatedly made at the PACOM and CONUS hospitals that, 
despite the impressions of evacuating surgeons that skin traction was “always” ap¬ 
plied before evacuation, skin traction was not maintained in the evacuation route. 
This was unfortunate because skin traction only to the distal two inches of skin was 
essential in the initial phases of treatment and evacuation, if early closure of the 
open amputation was to be achieved. This was true irrespective of the subsequent 
closure method, be it delayed primary closure, continued skin traction, skin graft¬ 
ing, or plaster socket and early ambulation. 

Therefore, should future wars require evacuation of amputees, a uniform inter¬ 
service education program should be designed that includes established guidelines 
and specific directives concerning maintenance of continued skin traction to the 
stump by self-contained methods. A well-applied plaster cast immobilizing the joint 
most proximal to the amputation level with attached outrigger continues to be the 
most satisfactory method of achieving this goal. 

Abrupt, massive bleeding from failure of the proximal vein graft anastomosis 
was observed in some amputees who had amputations through the thigh at the level 
of the grafting procedure. To prevent this dramatic complication, the vein graft 
should be removed and ligation of the most distal part of normal artery done at the 
time of amputation. 

Diverting colostomies should be done in patients with hip disarticulations, 
hemipelvectomy, and high above-knee amputations early in the course of treatment 
to decrease local fecal contamination of the wound. 

Myodeses and myoplasties have been described as beneficial in producing 
stronger and more functional stumps through reestablishment of myoneural reflex 
patterns. However, most of the traumatic-type amputations sustained in the war 
zone were not amenable to this procedure. Ertl osteoplasty revisions of the longer 
below-knee stumps were performed frequently in some centers. This procedure 
created a stump allowing more stability and a closer contact prosthetic fit with end 
weightbearing than the ordinary below-knee stump. It is recommended for se¬ 
lected, well healed below-knee stumps. 

Several innovations in prosthetic design and manufacture which occurred dur¬ 
ing the rehabilitation period of our Vietnam War amputee population proved bene¬ 
ficial. The Henche, Mauke S&S hydraulic knee was popular for the active young 
unilateral above-knee amputee. Stable four-bar linkage knee systems, sometimes in 
combination with the S&S knee unit, were utilized to ambulate the bilateral above¬ 
knee amputee in some centers (Mayfield 1971). 

Myoelectric devices to drive powered upper extremity protheses were intro¬ 
duced to selected upper extremity amputees through the Veterans Administration 
and Northwestern University combined research program. Acceptance rate was 
variable, however, and the more conventional “hook was the most widely ac¬ 
cepted terminal device for upper extremity amputees. 


152 


ORTHOPEDIC SURGERY IN VIETNAM 


In summary, many different types of amputee management were performed 
during our years in Vietnam. As the war progressed, the concept of maintaining a 
viable skeletal strut and retaining all possible viable skin flaps evolved as a basic 
guideline in most amputations. Meticulous debridement had no substitute, and in¬ 
cluded a search proximally for possible fragments or vascular injuries. Early evacu¬ 
ation had its advantages, but some patients suffered from lack of traction being 
maintained to the open stump. In CONUS, rehabilitative efforts were focused on 
early weightbearing for the lower extremity amputee and early functional use of the 
prosthesis (or orthesis) for the upper extremity amputee. 

REFERENCES 

Baker, G. I. 1970. Communications from the clinics. Newsletter. Amputee Clinics. 2, #1. 
Brand, P. W., and Ebner, J. A. 1969. Pressure-sensitive devices for denervated hands 
and feet. J. Bone and Joint Surg. (Am) 51:109-16. 

Brown, P. W. 1970. Rehabilitation of bilateral lower extremity amputees. J. Bone 
and Joint Surg. (Am) 52:687-700. 

Burgess, E. M.; Romano, R. L.; and Zetti, J. H. 1969. The management of lower ex¬ 
tremity amputations. Washington: Prosthetics and Sensory Aids Service, Veter¬ 
ans Administration. 

Burkhalter, W. E.; Mayfield, G. W.; and Carmona, L. S. 1976. The upper extremity 
amputee. Early and immediate post surgical fitting. J. Bone and Joint Surg. 
(Am) 58:46-51. 

CINCPAC-2. 1968. Commander in Chief, Pacific. Second CINCPAC Conference 
on War Surgery. Tri-service surgical conference conducted at John Hay Air 
Base, the Philippines, 25-28 March 1968. 

Deffer, P. R. 1970. More on the Ertl Osteoplasty. Newsletter. Amputee Clinics. 2, #1. 
Hampton, O. P, Jr. 1957. Orthopedic surgery in the Mediterranean Theater of Oper¬ 
ations. Office of The Surgeon General, Department of the Armv. Washington: 
GPO. 

Hampton. O. P., Jr. 1966. Report of consultant tour, 15 February-25 March 1966. 
Herndon, J. J.; Tolo, V. T.; LaNoue, A. M.; and Deffer, P. A. 1973. Management of 
fractured femurs in acute amputees. J. Bone and Joint Surg. (Am) 55-1600-1613. 
Keblish, P. A.; LaNoue, A. M.; and Deffer, P. A. 1970. Preservation of the short BK 
amputation stump with pedicle flaps. Presentation at Eastern Orthopaedic As¬ 
sociation Meeting. 

LaNoue, A. M. 1971. Care and disposition of amputee war casualties. Student 
Paper, U.S. Army Command and General Staff College. 

Mayfield, G. W. 1971. Experience with polycadence knee joint. Newsletter. Amputee 
Clines. 3, #2. 

Mayfield, G. W., and Bagg, R. 1978. Longitudinal survey of 169 RVN amputees cre¬ 
ated. (Unpublished data) 106th General Hospital (Japan). 

Mayfield, G. W., and Burkhalter, W. E. 1972. Treatment of open ambulation stumps 
by temporary prostheses and early ambulation. Scientific Exhibit, American 
Academy of Orthopaedic Surgeons Annual Meeting. 

Mazet, R., Jr., and Hennesy, C. A. 1966. Knee disarticulation and a new knee joint 
mechanism. J. Bone and Joint Surg. (Am) 28:126-39. 

Moss, J. H. 1970. More on the Ertl Osteoplasty. Newsletter. Amputee Clinics. 2, #2. 
NATO Emergency war surgery handbook. 1958. Department of Defense. Washing¬ 
ton: GPO. 


VIETNAM WAR AMPUTEES 


153 


Omer, G. E., Jr., and Pomerantz, G. M. 1972. Initial management of severe open in¬ 
juries and traumatic amputations of the foot. Arch. Surg. 105:696-98. 

Pennell, C. R., and Mayfield, G. W. 1972. Bent knee pylon for the below knee am¬ 
putee. Physical Therapy 52:1051-55. 

Utterback, T. D., and Rhobrer, D. W. 1973. Knee disarticulation level as an amputa¬ 
tion level. J. Trauma. 2:116-20. 

Wilber, M. C. 1970. Combat amputees. Clin. Orthop. 68:10-13. 

Wilson, P. D. 1969. Early weightbearing in treatment of amputations of lower limbs. 
J. Bone and Joint Surg. 4:224-47. 





















































8 


Peripheral Nerve Problems 

Colonel George E. Omer, Jr., MC, USA (Ret.), and 
Colonel William W. Eversmann, Jr., MC, USA (Ret.) 


Final disposition data from Army hospitals in Vietnam indicate an incidence of pe¬ 
ripheral nerve injuries of approximately 7.3 percent of the nonmortal wounds from 
1964 through 1973 (Bzik and Bellamy 1984; Rothberg et al. 1983). The same data indi¬ 
cated that 61 percent of 7.138 peripheral nerve injuries involved the upper extremity. 
Multiple nerve injuries were more common in the upper extremity. In a series of 653 
patients with upper extremity injuries, 188 extremities had multiple nerve involvement 
(Omer 1974). Combined neurovascular injuries are frequent in battlefield trauma. The 
Vietnam Vascular Registry (Rich and Spencer 1978) recorded concomitant nerve in¬ 
jury in 42.4 percent and fractures in 28.5 percent of 1,000 acute major arterial injuries. 

INITIAL SURGERY 

The presence or absence of a peripheral nerve injury was of very little conse¬ 
quence in the resuscitation and initial management of the wounded soldier. The nerve 
injury was the secondary result of the same hostile action that caused the extremity 
wound, which was handled in routine fashion. Associated fracture splintage and re¬ 
suscitation was followed by wound exploration. At the 85th Evacuation Hospital, at 
Qui Nhon, Vietnam, there was a concerted attempt made to identify the nerve injury 
preoperatively and to explore the damaged nerve during the debridement procedure. 
This effort had a dual purpose—to protect damaged nerves during the wound explo¬ 
ration, and to identify the nerve injury and try to address its implications for subse¬ 
quent management. The information that a median nerve that was nonfunctioning 
preoperatively had proved on exploration to be normal, contused, divided, or seg- 
mentally lost would be of enormous value to the doctors receiving the patient in the 
United States. Frequently, such information never reached the surgeons managing 
the patient definitively (Omer 1975). In most other hospitals in Vietnam, no definite 
search was made for the damaged nerve, but if one was found, a note was made re¬ 
garding its continuity or the degree of injury that could be determined grossly. 

Often, especially in the upper extremity, a vascular injury would accompany the 
nerve injury. Although in such a situation some note should be made regarding the 
status of the nerve which was in close proximity to the damaged vessel, this was often 
not done. If a note was made, it would not necessarily be accurate, and incorrect in¬ 
formation in such a circumstance could be more damaging than no information. 
Such mistakes were common, in part because only a few of the surgeons actually de- 
briding extremity wounds had extensive experience in peripheral nerve surgery or 
were well enough versed in the cross-sectional anatomy to be able to identify dam- 


156 


ORTHOPEDIC SURGERY IN VIETNAM 


aged nerves in the swollen, distorted extremity. In addition, since the main problem 
was wound debridement and vascular repair, surgeons were reluctant to search for 
damaged nerves before vascular repair because it would prolong the ischemic period 
to the limb. Searching after vascular repair, however, might compromise the repair. 

The diagnosis of peripheral nerve injury was more likely to be made in the com¬ 
munication zone, although it might be made on physical examination rather than by 
surgery. But an isolated peripheral nerve injury without fracture was not likely to be 
specifically addressed in a communication zone. Patient stabilization, wound con¬ 
trol, and subsequent wound closure were the major concerns, and nonoperative and 
occasional operative stabilization of fractures before evacuation to the zone of inte¬ 
rior were also carried out at this time. More frequently than not, wound closure 
would be obtained, rehabilitation of the extremity would be instituted, and splintage 
as required by occupational or physical therapy modalities or perhaps even a plaster 
cast would be added before the patient's evacuation. A patient with a long bone frac¬ 
ture might be held in the communication zone for a long period of time to gain some 
degree of skeletal stability before the application of the plaster cast for evacuation. 

Because causalgia would easily develop within one to two weeks of injury, it was 
usually first seen in the communication zone. It has always been felt, perhaps incor¬ 
rectly so, that causalgia is a problem that develops a number of weeks or months after 
the major mixed nerve injury, but our experience in Vietnam led us to conclude that it 
was essential to institute treatment early in order to bring about a successful conclusion 
of the causalgic problem. In general the more proximal the nerve injury and the less de¬ 
structive in character the wound, the more likely the patient was to develop a causalgic 
pattern. The management of causalgia is not controversial, but certainly the results of 
the treatment options are far better with the institution of early treatment. The sur¬ 
geons in the communication zone who initially recognized this phenomenon and began 
early sympathetic blocks and/or surgical sympathectomies are to be congratulated. 

Depending upon the patient flow, the amount of hostile action, and the presence of 
associated injuries, patients with peripheral nerve damage could arrive in the zone of 
the interior within a few days of the initial injury with open wounds, or they could ar¬ 
rive several weeks following the initial injury in a plaster cast with a surgically closed 
and clean wound. Nevertheless, our initial plan was to obtain wound control, then to 
close the wound, and finally to achieve skeletal stability and rehabilitate the patient’s 
injured limb. The time from nerve injury to definitive nerve repair or graft could be as 
long as a few weeks to several months. In most situations in the zone of the interior, 
the patient with a nerve injury had far more than an isolated nerve wound. He proba¬ 
bly had a diffuse extremity injury that required skin grafting or closure with flaps. Per¬ 
haps bone grafts for skeletal stability were needed before the nerve injury could be ad¬ 
dressed surgically. The surgeons responsible for these patients in the United States 
disagreed on their management. One group believed that as soon as the diagnosis of a 
peripheral nerve injury was made and as soon as the internal environment of the limb 
permitted an operative procedure, the nerve should be explored, grafted, or repaired 
as necessary (Brown 1970). A second group felt that spontaneous recovery was likely 
to occur in the majority of the patients and therefore, whether the injury was low or 
high velocity, watchful waiting and further rehabilitation of the limb was preferable to 
a secondary exploratory procedure (Omer 1982). In the majority of these cases, enter¬ 
ing the limb to deal with a nerve injury early or as soon as a closed wound had been 


PERIPHERAL NERVE PROBLEMS 


157 


obtained was probably not going to be useful. Surgical exploration might well be 
needed in a small number of patients treated by watchful waiting, limb rehabilitation, 
and other procedures that were required rather than by concentrating so much on 
nerve exploration and repair. Omer was a proponent of watchful waiting, as much of 
the published information from Brooke Army Medical Center in Texas confirms. Al¬ 
though Brown from Fitzsimons General Hospital in Colorado was a proponent of 
early nerve exploration and repair, as required, and/or neurolysis, Omer felt that, since 
most of the nerve injuries were concussive in nature and recovery was likely to occur, 
surgical exploration was meddlesome. 

Experience has demonstrated that the initial exploration and debridement and 
the delineation of the status of the nerve at the time of wounding (initial surgery) 
was extremely important. An additional exploration of the extremity could be 
avoided when a nerve palsy existed in a nerve that had already been explored and 
found to be in continuity although contused. 

SPONTANEOUS RECOVERY 

Sunderland studied, retrospectively, a series of patients during World War II and 
found spontaneous recovery in 68 percent (1972). Rakolta and Omer (1969) observed 
that spontaneous regeneration could be delayed up to eleven months without excluding 
the possibility of clinical recovery (table 8). Omer (1982) developed a prospective study 
of 595 gunshot wounds from Vietnam to determine the percentage of spontaneous re¬ 
covery. Spontaneous recovery occurred in 227 of 331 low-velocity gunshot wounds (69 
percent) and 183 of 264 high-velocity gunshot wounds (69 percent) (table 9). 

Table 8.— Interval between injury and spontaneous recovery in gunshot wounds 12 


(Neurapraxia) (Axonotmesis) (Axonotmesis) 


Nerve 0-4 months 4-9 months 9 + months 


Radial. 20 9 2 

Median. 10 7 — 

Ulnar. 9 13 4 

Sciatic and Popliteals. 14 14 3 

Femoral. 1 4 1 


Total (111). 54 47 10 


1 Rakolta, George G. and Omer, George E., Jr. Combat-sustained femoral nerve injuries. Surg. Gynecol. Obstel. 128:813-817. 1969. 

2 Seddon, Herbert J. Surgical disorders of peripheral nerve. Second edition. Edinburgh: Churchill Livingstone, 1975. 


Prognosis is more accurate if the time required for return of clinical function is 
known. Omer (1974) selected two parameters for a time frame: (a) the interval 
after injury at which one-half of the nerves had recovered function, and (b) the in¬ 
terval after injury after which only 10 percent of the nerves recovered function. 
This established a time frame from three to nine months in 90 percent of the nerve 
lesions that demonstrated spontaneous recovery. Proximal (high) extremity injuries 
took a longer time to show clinical function than distal (low) injuries. Extensive in¬ 
juries producing multiple nerve lesions needed a longer time period to show clinical 
function than isolated nerve injuries (table 10). 












158 


ORTHOPEDIC SURGERY IN VIETNAM 


Table 9. —Time scale in months for spontaneous recovery in gunshot wounds 1 



Isolated Nerve Lesions 



Above-the-elbow 

Below-the-elbow 

Low-Velocity.. 

High-Velocity.. 

. 4-7 mos. (48) 

. 3-6 mos. (31) 

3-6 mos. (90) 
3-6 mos. (32) 


Multiple Nerve Lesions 



Above-the-elbow 

Below-the-elbow 

Low-Velocity. 

High-Velocity. 

. 5-8 mos. (41) 

. 5-9 mos. (65) 

3-7 mos. (48) 
5-8 mos. (55) 

Total (410) 

(185) 

(225) 


1 Omer, George E„ Jr. Injuries to nerves of the upper extremity. J. Bone Joint Surg. (Ant.) 56A:1615-1624, 1974. 


Table 10. —Summary of upper extremity nerve injuries at Brooke Army Medical Center 


Nerve injury per extremity Number of extremities Total nerve lesions 


Single. 475 475 

Double. 137 274 

Triple. 36 108 

Quadruple. 15 60 


Total. >663 917 


1 Ten patients had bilateral involvement. 

Source: Omer, George E., Jr. 1974. Injuries to nerves of the upper extremity. J. Bone Joint Surg. 56A:1615-1624. 


MANAGEMENT OF PAINFUL NEUROMA 
IN CONTINUITY AND CAUSALGIA 

Many clinical syndromes involving burning pain, abnormal vasomotor response, 
and dystrophy have been described in medical literature since the American Civil 
War, the first major conflict in which high-velocity missile injuries were common. The 
dreadful pain associated with penetrating injuries of nerves was best described by S. 
Weir Mitchell, George R. Morehouse, and William W. Keen in their monograph in 
1864, although the condition of causalgia had been described as early as 1813 by A. 
Denmark, another military surgeon whose patient was wounded in the arm at the 
storming of Badajoz (Sunderland 1972). Classic causalgia may have variants that are 
termed Leriche’s posttraumatic pain syndrome (minor causalgia), Sudek’s atrophy, or 
shoulder-arm-hand syndrome (Lankford 1980). 

The incidence of causalgia has generally varied with the criteria used for diagno¬ 
sis. Data from World War I and World War II indicate that causalgia occurs in 2 to 4 
percent of wounds involving major nerves (Rothberg et al. 1983). Omer and 
Thomas (1972) indicated that in a 54-month Vietnam series, 74 percent of the cases 
of causalgia involved the median or sciatic-tibial nerves. These cases included a 
high incidence of multiple nerve injuries; only 21 percent were due to wounds distal 
























PERIPHERAL NERVE PROBLEMS 


159 


to the elbow or knee. The lower extremity was involved more often than the upper 
extremity (table 11). In 49 percent of the cases in this Vietnam series, the onset of 
pain was within the first twenty-four hours after injury, and in 70 percent, it oc¬ 
curred within the first week (table 12). 


Table 11.— Causalgia: Nerves involved (1966-70), during Vietnam War 1 


Nerve 

Number of cases 

Level of injury 

Above elbow or knee Below elbow or knee 

Upper Limb Brachial Plexus. 

8 

8 


Median. 

25 

15 

10 

Ulnar. 

2 

1 

1 

Radial. 

1 

— 

1 

Lower Limb Sacral Plexus. 

7 

7 

— 

Sciatic. 

24 

24 

— 

Tibial . 

8 

4 

4 

Peroneal. 

1 

1 

— 

Femoral. 

1 

1 

— 

Total. 

77 

61 

16 


1 Omer, George E.. Jr. and Thomas, S. R. 1972. Abstract: Peripheral periodic infusion sympathectomy for the treatment of causalgia. J. 
Bone Joint Surg. (Am.) 54: 898-899. 


Table 12.— Causalgia: Time of onset of symptoms (1969-70), during Vietnam War 1 


Time Upper extremity Lower extremity Total 


Day of Injury. .. 18 20 38 

First Week. 9 7 16 

One-Three Weeks. 5 9 14 

Three-Six Weeks. 3 2 5 

Over Six Weeks. 1 3 4 


Total. 36 41 77 


1 Omer, George E., Jr. and Thomas, S. R. 1972. Abstract: Peripheral periodic infusion sympathectomy for the treatment of causalgia. J. 
Bone Joint Surg. (Am.) 54: 898-899. 


Chemical Blocks 

Treatment should be instituted as soon as the syndrome causalgia is suspected 
(tables 13 and 14). A central chemical sympathetic block should be performed 
promptly as a diagnostic test as well as a therapeutic procedure. The anterior ap¬ 
proach is preferred for a stellate block, with a paravertebral injection of the lumbar 
sympathetic chain. While the patient is free from pain, an accurate physical examina¬ 
tion of the extremity can be performed. Subsequent central blocks may utilize an 
anesthetic agent with a longer duration, such as bupivacaine. A series of four or five 
blocks should be given on consecutive days; one placebo of normal saline solution 
should be given during the series to confirm the diagnosis. The potential for the series 
of blocks to give permanent relief of pain is uncertain, but some generalizations were 
made. One block may give total relief or reduce residual pain to a tolerable level. The 




























160 


ORTHOPEDIC SURGERY IN VIETNAM 


effective duration of the first block may exceed that expected of the agent, and subse¬ 
quent blocks may give progressively shorter pain-free periods. Lastly, the block gives 
relief only for the duration expected from the anesthetic agent used (Omer and Sey¬ 
mour 1969). If the block series produces total relief or reduction of pain to a tolerable 
level for progressively longer pain-free periods, the prognosis for permanent im¬ 
provement is excellent. If the block series gives shorter pain-free periods or less relief 
than expected, permanent improvement should not be expected (Bzik 1984). 


Table 13 .— Causalgia: Causative agent (1966-78), during Vietnam War 1 


Agent 

Upper extremity Lower extremity 


Total 

Gunshot Wound. High-Velocity 


18 

23 


41 

Fragment Wound. 


12 

14 


26 

Crush Wound. 


3 

2 


5 

Aircraft Accident. 


1 

2 


3 

Stab Wound/Injection. 


2 

0 


2 

Total. 


36 

41 


77 

1 Omer, George E., Jr. and Thomas, S. 

R. 1972. Abstract: Peripheral periodic infusion sympathectomy for the treatment of causalgia. J. 

Bone Joint Surg. (Am.) 54: 898-899. 






Table 14.— Causalgia: Results of treatment (1966-70), during Vietnam War' 




Improved 


Failure 

Method 

Cases 

Upper Lower 


Upper 

Lower 

Chemical Sympathectomy: 






Central Block. 

43 

7 11 


11 

14 

Epidural (Spinal Cord). . . 

4 

4 


— 

— 

Peripheral Infusion. 

30 

5 9 


2 

14 


77 

36 (47%) 



41 (53%) 

Surgery: 






Central Sympathectomy . . 

37 

20 14 


1 

2 

Destruction of Nerve .... 

2 

- - 


2 

— 

Neurolysis. 

1 

— — 


1 

— 

Removal of Foreign Body. 

1 

1 


— 

— 


41 

35 (85%) 



6 (15%) 


, 1 Omer. George E., Jr. and Thomas, S. R. 1972. Abstract: Peripheral periodic infusion sympathectomy for the treatment of causalgia. J. 

Bone Joint Surg. (Am.) 54A: 898-899. 


The technique for a peripheral chemical sympathectomy in an extremity was de¬ 
veloped at Brooke General Hospital during the Vietnam War (Omer and Thomas 
1971, 1972, 1974). When the patient with causalgia was examined, the involved ex¬ 
tremity was tapped very gently from distal to proximal to demonstrate any “trigger 
points" of extreme irritation. If a “trigger point" was found, the area was surgically 
prepared and marked with a sterile pen. After local cutaneous anesthesia, a 16-gauge 
needle was inserted into the area of irritation. The needle was aspirated to avoid 
blood vessel penetration, and a flexible 18-gauge polyethylene intravenous catheter 
was inserted through the 16-gauge needle. (If performed in this manner, the intra- 
























PERIPHERAL NERVE PROBLEMS 


161 


venous catheter should not penetrate a nerve or blood vessel.) The larger bore 16- 
gauge needle was removed, and the catheter was left in place so that infusions could 
be injected without another skin puncture. One-half milliliter of 0.5 percent lidocaine 
hydrochloride was injected into the intravenous catheter for anesthetic effect. If the 
“trigger point” pain was relieved, the venacatheter was capped and taped in place. 
The anesthetic block usually was insufficient for complete motor or sensory paralysis. 

The pain-free patient was asked to exercise the extremity, to walk, and to perform 
assigned physical therapy. If the anesthetic block was not effective, an additional 
milliliter of lidocaine was injected periodically. The patient decided the frequency of in¬ 
jection, dependent upon pain relief. The usual regimen was 2 percent lidocaine hy¬ 
drochloride solution with 1/100,000 epinephrine every four hours. The volume for each 
injection ranged from 0.5 to 1 ml., and the time between injections ranged from one to 
ten hours. The average time between injections was 2.2 hours during the acute stage, 
and 3.4 hours as the effect of the peripheral sympathectomy decreased pain and muscle 
strength improved. Infusions were continued for two weeks in a few cases. If there was 
more than one area of irritation, separate intravenous catheters were used for each 
“trigger point” (fig. 45). In contrast to a central chemical stellate block, the peripheral 
sympathectomy is a ward procedure that could be performed simultaneously with other 
modes of treatment. The peripheral sympathectomy should block the local formation 
of neurokinin more effectively than the central chemical block. It relieves painful symp¬ 
toms for a variable period of time, but is much less effective in those cases where the 
pain has been untreated and unrelieved for three months or more after injury. 

During the Vietnam War, the peripheral chemical sympathetic blockade was used for 
causalgia and other reflex sympathetic overflow syndromes as well as for specific periph¬ 
eral nociceptive increased stimuli, such as neuroma. While peripheral chemical sympa¬ 
thetic block was used for all painful conditions in an extremity, its major usefulness was 
in the management of peripheral neuroma in continuity. This was especially true if there 
was significant remaining distal motor and sensor function. The causalgia that responded 
to a series of stellate ganglion blocks was usually treated by sympathectomy (fig. 46). 
Baker and Winegamer (1969) and Omer and Thomas (1971, 1972, 1974) reported im¬ 
provement in 59 and 65 cases following surgical sympathectomy during the Vietnam 
War. The transaxillary approach was preferred over the posterior transcostal approach. 

The sympathetic chain was removed from the fourth thoracic level superior to 
include the lower half of the stellate ganglion. Horner’s syndrome, which could be 
annoying to the patient, was present less often after the transaxillary approach, 
which permits removal of only the lower half of the stellate ganglion, than after the 
supraclavicular approach. In the lower extremity, a retroperitoneal approach 
through a lateral flank incision, as described by White and Sweet in 1969, allowed 
removal of the sympathetic ganglions from the second to the fifth lumbar level. 
Postoperative precise sudomotor function tests demonstrated whether sympathetic 
enervation of the involved extremity was complete. 

Interviews with patients who were not improved by peripheral chemical blocks or 
surgical sympathectomy indicated a trend toward gradual tolerance to the pain after 
three years or more. The pain still was considered severe, but no longer dominated the 
patient’s life, and most activities of daily living could be performed. Experience also 
demonstrated that if the chemical peripheral or central sympathetic blockade is not ef¬ 
fective, permanent improvement by surgical sympathectomy should not be expected. 


162 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 45.—'The “trigger point” is demonstrated with retrograde tapping (Tinel's sign) 
from distal to proximal along the nerve trunk. Local anesthesia is used just proximal to 
the trigger point. A flexible intravenous catheter is inserted through the needle. Local 


















































PERIPHERAL NERVE PROBLEMS 


163 




anesthetic is injected through the intravenous catheter. If pain is relieved, the ve- 
nacatheter is capped and taped to the extremity. Multiple injections could be used. 





























































164 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 46.—Surgical scar following surgical 
sympathectomy. The clips demonstrate the ex¬ 
tent of the sympathetic chain that was removed. 





PERIPHERAL NERVE PROBLEMS 


165 


Phantom Pain 

A significant problem in the military population is phantom pain. Following an 
amputation, an adult feels as if the nonexistent limb were still present. It may feel ex¬ 
actly like the original limb as to shape, size, position, and ability to move. These sen¬ 
sory phenomena are termed phantom and may persist for varied periods of time. The 
phantom has been reported to continue from six months to twenty years (Frazier and 
Kalb 1970). Phantom pain is an entirely different dimension than is phantom sensa¬ 
tion. The patient with phantom pain resulting from physical causes can usually be dis¬ 
tinguished from one with psychogenic pain (Frazier and Kalb 1970). When the cause 
is physical, the patient has a period of no pain following amputation, and the onset of 
pain follows nerve distribution. The patient with psychogenic problems has pain im¬ 
mediately following amputation, the pain does not follow nerve distribution, and it is 
evoked especially by reference to disturbing events. A review of more than 7,000 am¬ 
putees from World War II and Korea treated at the Navy amputation center in Oak¬ 
land found that phantom pain exists in approximately 2 percent of amputees (Canty 
and Bleck 1958). Omer (1976, 1981) had an experience similar to that of Ewalt, who 
reported that only 8 of 2,284 military amputees suffered phantom pain (Ewalt et al. 
1947). Amputee patients have a common psychological disturbance and, with the ad¬ 
vantage of group therapy, should have similar goals. Fitzsimons Army Medical Cen¬ 
ter developed a comprehensive program to encourage the new amputee to abandon 
bedridden activities and enter the world of other amputees (Brown 1970b). Thera¬ 
peutic procedures included organized athletics and social activities. Functional activ¬ 
ity was supported by peers with similar problems, and their assurance was of greater 
value to the patient than the prescriptions of therapists and surgeons. The utilization 
of group therapy was recognized as the major factor in rehabilitation. Peripheral 
nerve irritation, abnormal sympathetic function, and psychological factors all con¬ 
tribute to phantom pain (Omer 1981). The treatment program for every amputee af¬ 
flicted with this difficult syndrome must be approached on an individual basis. 

Functional Activity 

The second principle in all treatment programs for pain is functional activity for 
the involved extremity. Physical modalities may be divided into passive and active 
assistors. The passive activities will improve circulation, decrease edema, prevent 
contracture, and prepare the patient for voluntary participation in the active exer¬ 
cise program. Passive modalities include elevation, traction, plaster casts, static 
splints (orthoplast), vibrators, faradic muscle stimulation, microwaves, ultrasound, 
ice packs, hot paraffin packs, combined contrast baths, massage, and inflatable 
splints with positive-negative pressure. Delicate desensitization techniques used to 
help the apprehensive patient include stroking the skin lightly with a feather, fol¬ 
lowed by gentle massage, and progressing to hot paratfin baths. Other desensitiza¬ 
tion techniques include contact with foam rubber chips, jelly beans, navy beans, and 
rice to provide progressively greater contact pressure (Omer 1984). Some passive 
modalities may be contraindicated in some cases—the whirlpool bath, lor example, 
involves dependent heat and may increase edema and inflammatory ieaction. 


166 


ORTHOPEDIC SURGERY IN VIETNAM 


The more important phase in use of the extremity is active exercise, which can be 
assisted with dynamic splints, supportive exercising slings, and special handles for 
tools. Special care must be directed to key circulation areas, such as the rotator cult 
muscles in a shoulder-arm-hand syndrome. General body condition is important, and 
the patient should be ambulatory, if at all possible, to meet his environment. Function 
can be developed with diversional games, assigned work, and activities of daily living. 

Physicians, physical therapists, occupational therapists, and other attendants 
must be compassionate and yet stimulate maximal effort in the patient. The best 
functional activity is a patient who has returned to active military duty. Ultimately, 
the patient “cures” his own case. 

When pain has subsided, elective surgery such as tenolysis and joint releases 
may be undertaken in order to regain motion after an extensive physical medicine 
program has been faithfully performed by the patient. Elective surgery performed 
without these safeguards is ill-advised. 

SURGICAL TECHNIQUES 

Five annual conferences on war surgery were held in the Pacific from 1967 
through 1971. All proceedings emphasized the value of a complete description of 
the nerve injury as observed at debridement. An appropriate debridement includes 
incisions into the area of injury, with evaluations of the damage to adjacent tissue, 
of the state of the musculature, and of the exact site of the neurovascular lesion. An 
estimate of the percentage of laceration or disruption should be reported. Delayed 
primary closure was recommended for the extremity wound. Primary nerve suture 
was discouraged because neurorrhaphy should be performed in the hospital provid¬ 
ing definitive care (CINCPAC-2, 1968) (tables 15 and 16). 


Table 15 .—Vietnam neurorrhaphy related to etiology and level of injury 1 


Etiology 

Number 

Adequate 

followup 

Clinical 

return 

Percentage 

Lacerations: 

above-elbow. 

9 

8 

3 

37 

below-elbow. 

90 

67 

30 

45 

High-velocity gunshot: 

above-elbow. 

24 

21 

6 

28 

below-elbow. 

24 

14 

6 

43 

Low-velocity gunshot: 

above-elbow. 

19 

18 

9 

50 

below-elbow. 

16 

14 

6 

43 

Fracture—Dislocations: 

above-elbow. 

1 

1 

0 

0 

below-elbow. 

1 

0 

0 

0 

Total. 

183 

143 

60 

42 


1 Omer. George E., Jr. 1974. Injuries to nerves of the upper extremity. J. Bone Joint Surg. (Am.) 56:1615-1624. 















PERIPHERAL NERVE PROBLEMS 


167 


Table 16. — Vietnam neurorrhaphy secondary suture—specific nerves 12 


Number returned Some returned 

Nerve Number repaired Number (Percent) Number (Percent) 


Ulnar. 68 44 (65) 24 (35) 

Median. 38 19 (50) 19 (50) 

Radial. 5 3 (60) 2 (40) 

Digital. 24 10 (40) 14 (60) 

Total. 135 76 (56) 59 (44) 


1 Brown. P. W.: The time factor in surgery of upper-extremity peripheral nerve injury. Clin. Ortliop. 68:14-21, 1970. 

: Brown. P. W.: Factors influencing the success of the surgical repair of peripheral nerves. Surg. Clin. North Am. 52:1137-1156, 1972. 


Nerve Injury and Repair 

Sharp lacerations that do not involve loss of nerve tissue and are allowed to per¬ 
sist for a number of weeks or months create nerve gaps. In complex extremity in¬ 
juries with fractures and tissue loss, the nerve gap may result from scarring and loss 
of nerve substance. Overcoming nerve gaps was a significant problem for surgeons 
in the zone of interior. 

World War II studies (Woodhall and Beebe 1956) indicated an average loss of 6 
percent from the optimal motor recovery for every centimeter of nerve gap. A nerve 
gap of 7.5 centimeters was the maximum amount that could be approximated without 
requiring rigid immobilization of the extremity in flexion (Omer 1976). During the 
Vietnam War, the techniques used to close a nerve gap included: 

Mobilization of nerve trunk. This longitudinal release forces the nerve to sur¬ 
vive on its internal longitudinal circulation. 

Shortening the skeleton. Potentially dangerous because all soft tissue structures, 
such as muscle-tendon unit, are relatively lengthened and weakened. 

Bulb suture. An unacceptable technique because it produces acute stretch of 
the nerve. There should be minimal longitudinal tension, and functional failure has 
been reported when stretching as little as 5 percent of the length (Lui et al. 1948). 

Transposition and rerouting. An example is transferring the ulnar nerve from 
the extensor to the flexor surface at the elbow (fig. 47). At Letterman General Hos¬ 
pital, Mutz recorded that 3 to 5 centimeters of radial nerve could become available 
to close a gap by anterior transposition of the nerve following dissection of the 
proximal segment to the level of the posterior cord ol the brachial plexus. II a 
choice is available, the distal portion of a nerve should be rerouted, since the proxi¬ 
mal portion contains the regenerating axons. 

Flexion of joints. The elbow or knee should not flex beyond 90 degrees, nor the 
wrist beyond 30 degrees. After the initial healing period ol thiee to six weeks, joints 
should be extended only 10 degrees per week to prevent intrinsic ischemia (Highet 
and Sanders 1943). 

Nerve grafts. Autogenous material is preferred for graft; the sural nerve and the 
medial or lateral antebrachial cutaneous nerve are the best sources. 













168 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 47. —The ulnar nerve has been freed from the ulnar groove and the muscles in¬ 
serting into the medial epicondyle, then transposed to the anterior aspect of the upper 
extremity for an epineurial repair. 


During the Vietnam War, the use of magnification, delicate instruments, and 
finer, less reactive suture material improved the techniques of nerve suture. In addi¬ 
tion, battle area evacuation was more expeditious. An effort was made to perform 
suture as early as possible. Seventy percent of the successful anastomoses were per¬ 
formed within six weeks of injury (Omer 1974). The majority of sutures were per¬ 
formed within the first 3 months after injury. Omer (1974) reported the results of 
143 epineural sutures of upper extremity nerves followed for at least twelve months 
and Brown (1970) recorded the results of 135 epineural sutures followed 6 to 24 
months (table 16). Neither study had adequate follow-up, and the results are not 
fully graded. Brown (1970b) states “some return.” Omer (1974) has two criteria for 
“clinical return”: for above-elbow lesion—progressive motor return with indepen¬ 
dent movement and point localization of 3.84 von Frey filament without over-re¬ 
sponse (M3-S2); for below-elbow—progressive motor return with independent 
movement and two-point discrimination, less than 20 millimeters (M3-S3) was 
needed. In addition, Omer (1974) noted that none of his patients with above-elbow 
neurorrhaphy had recovery of the intrinsic muscle of the hand during the period of 
study. The results of the two Vietnam series were similar and indicated that only 40 
to 45 percent of sutured nerves result in progressive functional return. Final recov¬ 
ery was not complete and therefore not evaluated. We now know there is significant 
recovery up to five years (Omer 1990, 1991). 



PERIPHERAL NERVE PROBLEMS 


169 


Neurolysis 

Neurolysis has often been recommended when an intact nerve was found on explo¬ 
ration ot a nonfunctioning nerve. During World War II, according to Woodhall and 
Beebe (1956) neurolysis was external in 70 percent of cases, with saline injection in 25 
percent and fascicular dissection in 5 percent. These authors found no evidence that 
internal and external neurolyses differed in their effect on recovery. During the Viet¬ 
nam War neurolysis was primarily an external technique. Brown (1970) utilized mag¬ 
nification at Fitzsimons General Hospital to perform intraneural fascicular dissection. 

Omer (1974) performed external and internal neurolysis in 59 cases in which the 
injured nerve was found in continuity, but bound in scar. When 50 of the cases were 
followed more than three months, neurolysis was found to have been successful in 60 
percent of the nerves. The return of function was more successful in above-elbow le¬ 
sions (18 of 29 nerves compared with 12 of 21 nerves in below-elbow lesions). 

There is doubt concerning the success of a neurolysis if function of the extremity 
returns during the time scale for spontaneous recovery after injury. The intact nerve 
may have recovered without the surgery. In those patients (table 17) who had neu¬ 
rolysis, 12 recovered function during the time frame for spontaneous recovery. 
Therefore, Omer (1974) considered the net result of neurolysis as successful in only 
18 (36 percent) of 50 nerve lesions. Kline’s subsequent studies would indicate an in- 
vivo nerve action potential study during the neurolysis procedure (Kline and De- 
Jong 1968; Kline 1980, 450-61). 


Table 17. —Vietnam cases 1 with external neurolysis 


Function return in 
the time range for 

3 month or Clinical return spontaneous 

Etiology more followup of function recovery Net result 


25 high-velocity gunshot. 24 9 3 6 

24 low-velocity gunshot. 21 16 7 9 

5 fractures. 4 4 2 2 

5 lacerations. 1 1 0 1 


59 Total. 50 30 12 18 


1 Omer, George E„ Jr. 1974. Injuries to nerves of the upper extremity. J. Bone Joint Sitrg. (Am.) 56:1615-1624. 


Nerve Grafts 

Only a limited number of grafts were performed during the Vietnam War (table 
18). Most of these were free cable or pedicle grafts done without consideration for 
precise longitudinal alignment of the fasciculi groups. No information is retrievable 
concerning the nerve gap that was closed or the longitudinal tension on the nerve 
graft. All were delayed procedures, more than three months after injury. Only four 
of thirty-four grafts (12 percent) demonstrated functional activity. 

The number of nerve grafts performed was small, the follow-up was variable, and 
the results were disappointing. Usually the battle-injured peripheral nerve had a 
scarred bed and a long gap secondary to nerve loss. Often, a long time had passed 











170 


ORTHOPEDIC SURGERY IN VIETNAM 


from injury to graft. Frequently the injury was proximal so the distance that regener¬ 
ating axons had to travel was long. All of these factors would portend a poor result. 

A cable graft is preferable to a full-thickness main nerve trunk graft because the 
full-thickness graft is in jeopardy of inadequate revascularization with central 
necrosis. The technique involves a microsurgical anastomosis with several cables of 
fascicular groups matched to the pattern of fascicular groups in the proximal and 
distal trunks of the injured nerve. Nerve grafts should be done by an experienced 
surgeon and as soon as clinically possible after the nerve injury (fig. 48). 

Table 18. —Autogenous grafts of major nerves—Vietnam War 1 


Autogenous grafts 

Types of grafts No return Clinical return 


Upper limb: 

Cable. 20 

Pedicle. 3 

Lower limb: 

Cable. 7 

Pedicle. 0 


Total (34). 30 


2 

0 

0 

2 


4 


1 Onier, George E., Jr.: Survey of Peripheral Nerve Injuries and Management Techniques (Committee on the History of Orthopaedic 
Surgery in Vietnam), May 14, 1974. 



Figure 48.— Fascicular bundle nerve grafts of the ulnar nerve in the forearm to esta- 
balish longitudinal internal alignment. The sural nerve was the donor for these grafts. 


EXTREMITY RECONSTRUCTION 
Motor Function 

Several surgical techniques were developed during the Vietnam War for se¬ 
lected early tendon transfers to serve as internal splints and to enhance function 
while awaiting nerve regeneration in the upper extremity (Brown 1969; Burkhalter 














PERIPHERAL NERVE PROBLEMS 


171 


1974; Omer 1968). The objectives of early tendon transfers are to stimulate sensibil¬ 
ity reeducation and to improve the coordination of residual muscle-tendon units. 
The muscle-tendon units used for early internal support should be synergistic with 
the muscle-tendon unit to be replaced, such as a wrist flexor in substitute for a fin¬ 
ger extensor. A synergistic tendon will be able to utilize spinal reflex arcs and other 
automatic feedback mechanisms to enhance reeducation. Two principles are fol¬ 
lowed: use as few muscle-tendon transfers as possible, since any active muscle-ten¬ 
don unit used to restore a useful extremity position will weaken the strength of the 
residual active function; and avoid performing a muscle-tendon transfer that will 
cause deformity when the nerve function recovers. 

Burkhalter and associates (1968) utilized a direct transfer of the extensor indicis 
proprius to restore thumb opposition in median palsy (fig. 49). This extensor mus¬ 
cle-tendon transfer has the advantage of introducing new strength into a weakened 
power-train for flexion, while conventional flexor muscle-tendon transfers for 
thumb opposition, such as the ring flex digitorum superficialis, represent a rear¬ 
rangement of volar muscle strength already committed to flexion activity. 

Omer (1974b) stabilized the clawed ring and little fingers and improved thumb- 
index pinch power in low ulnar palsy with a single flexor digitorum superficialis (fig. 
50). The flexor digitorum superficialis cannot be used if the ulnar innervated portion 
of the flexor digitorum profundus is paralyzed. The flexor digitorum superficialis is 
first split longitudinally, and the ulnar half is again split into two slips. The two slips 
of the ulnar half of the tendon are directed volar to the intermetacarpal ligament 
into one of two possible insertions; either into the central slip of the extensor mecha¬ 
nism insertion on the middle phalanx or into the A-2 pulley of the flexor sheaths in 
the ring and little fingers. The transfer should correct metacarpophalangeal hyperex¬ 
tension and improve interphalangeal coordinated flexion. The radial half of the su¬ 
perficialis tendon is directed across the adductor pollices, distal to the volar palmar 
ligament and dorsal to the flexor tendons, into the insertion of the abductor pollices 
brevis for improved pinch strength and to reinforce thumb pronation. 

If a power grip is a major consideration, Burkhalter and Strait (1973) lengthen 
the extensor carpi radialis longus or the brachioradialis with a multiple tailed free 
tendon graft through the lumbrical space, volar to the intermetacarpal ligament, to 
an insertion on the radial aspect of the proximal phalanx of the clawed digits. This 
transfer introduces new power from extensor muscles into the flexion action. 

These innovative muscle-tendon transfers were designed for early active use of 
the upper extremity as soon as possible after injury and neurorrhaphy (table 19). In 
a great many other patients, traditional muscle-tendon transfers were performed. 
Over a four-year period at Brooke General Hospital, 155 patients had multiple ten¬ 
don transfers for isolated or combined nerve lesions of the upper extremity (tables 
20-26) (Omer 1974b). The team approach utilized at all Army General Hospitals 
and most Army Station Hospitals included surgeons, physical therapists, occupa¬ 
tional therapists, orthotic and prosthetic technicians, plaster technicians, social 
workers, and others interested in the total rehabilitation of the patient. The patient 
was on a ward near others with similar injuries. The patients gave each other peer 
support and friendly competition. 


172 


ORTHOPEDIC SURGERY IN VIETNAM 




Figure 49. —Schematic of extensor indicis proprius transfer to provide thenar abduc¬ 
tion and tension of this transfer at the operating table. 
















PERIPHERAL NERVE PROBLEMS 


173 



Figure 50. —Tendon transfer of either the long or ring FDS for thumb adduction and 
to prevent clawing of ring and little fingers. The radial half of the split tendon passes 
volar to the adductor pollicis but dorsal to the FDP and FDS tendons to insert near the 
abductor tubercle of the proximal phalanx of the thumb. The two slips of the ulnar half 
of the transferred tendon can go volar to the intermetacarpal ligament to insert in the 
central slip of the extensor mechanism or to the A2 pulley for flexion of the MCP joint, 
which permits the extrinsic extensor the extend the interphalangeal joints. 



























174 


ORTHOPEDIC SURGERY IN VIETNAM 


Table 19. — Early tendon transfers as internal splints 1 


Palsy 

Functional need 


Motor muscles 

Low Median 

Thumb opposition (APB) 

Extensor indicis proprius 
(or) 

Flexor digitorum 
superficialis (ring) 

Palmaris longus 
(or) 

Extensor digiti quinti 

Radial 

Wrist extension (ECRB) 

Pronator teres 

Low Ulnar 

Thumb adduction (AP) 
and 

Finger clawing (interosseoi) 

Multi-tailed flexor digitorum 
superficialis (ring) 

(or) 

Extensor indicis proprius 
(3rd-4th metacarpal 
interspace) 

(plus) 

Brachioradialis (plus graft) 

1 Omer. George E.. Jr. 1983. The palsied hand. Ch. 16 in Surgery of the Musculoskeletal System, vol. L. ed. C. McCollister Evarts, Lon¬ 
don: Churchill Livingstone. 


Table 20. — Median 

nerve palsy 12 - 3 


Needed function 

Preferred motor 


Alternate motors 

Index and long finger flexion 
(FDP—index and long) 

Flexor digitorum profundus 
tenodesis in forearm 

Tenodesis, flexor digitorum 
profundus at DIP joint 

Thumb flexion (FPL) 
distal phalanx 

Brachioradialis 


Extensor Carpi radialis longus 

Thumb abduction for 
opposition (APB) 

Extensor indicis 
propius 

(Low) (High) 

Palmaris longus Extensor carpi ulnaris 

(or) 

Extensor digiti quinti 
(or) 

Flexor digitorum 
superficialis (ring) 

Sensibility (thumb-index) 

Neurovascular 

cutaneous 
island pedicle 
from ring 
finger 

Free neurovascular Free vascularized 

cutaneous island nerve graft 

flap 


1 Omer, George E., Jr., et al. 1970. Neurovascular cutaneous island pedicles for deficient median-nerve sensibility. J. Bone Joint Sure 
(Am.) 52:1181-1192. 

- Omer, George E.. Jr. 1968. Evaluation and reconstruction of the forearm and hand after acute traumatic peripheral nerve injuries. J 
Bone Joint Surg. (Am.) 50:1454-1478. 

' Omer. George E.. Jr. 1983. The palsied hand. Ch. 16 in Surgery of the Musculoskeletal System , vol. 1. ed. C. McCollister Evarts, Lon¬ 
don: Churchill Livingstone. 















PERIPHERAL NERVE PROBLEMS 


175 


Table 21. — Radial nerve palsy 1 


Needed function 

Preferred motor 

Alternate motors 

Wrist extension (ECRB) 

Pronator teres 


Finger extension (EDC) 

and thumb extension (EPL) 

Flexor carpi ulnaris 
(or) 

Flexor digitorum superficialis 
(long and ring) 

Palmaris longus to extensor 
pollicis longus 

Proximal thumb stability (APL) 

Split insertion—flexor carpi 
radialis to abductor pollicis 
longus 

(or) 

Palmaris longus tenodesis with 
extensor pollicis brevis 

1 Omer, George E.. Jr. 1983. The palsied hand. Ch. 16 in Surgery of the Musculoskeletal System, vol. 1, ed. C. McCollister Evarts, Lon¬ 
don: Churchill Livingstone. 


Table 22. —Ulnar nerve palsy 1 


Needed function 

Preferred motor 

Alternate motors 

Thumb adduction (AP) 
key pinch 

Brachialis with free graft 
between 3rd-4th metacarpal 
to abductor tubercle 

1st metacarpal 

Direct insertion, flexor 
digitorum superficialis 
(Edgerton/Brand/Goldner) 
(or) 

Split insertion, flexor 
digitorum superficialis 
(or) 

Extensor indicis proprius 

Metacarpal-phalangeal joint 
flexion/interphalangeal joint 
extension (integration of 

MP and IP motion) 

Extensor carpi radialis longus 
(Brand/Burkhalter to all 
four fingers with free graft 
to either flexor sheath or 
dorsal apparatus 

Flexor digitorum superficialis 
(Stiles/Bunnell) 

(or) 

Flexor carpi radialis 

Index abduction (first dorsal 
interosseous) 

Abductor pollicis longus slip 
to insertion of first 
dorsal interosseous 
(and) 

Arthrodesis, MP joint 
of thumb 

Extensor pollicis brevis 
(or) 

Extensor indicis proprius 

Finger flexion (FDP—ring 
and little) 

Flexor digitorum profundus 
tenodesis 

Tenodesis, FDP. at DIP joint 

Wrist flexion (FCU) 

Flexor carpi radialis to insertion 
of flexor carpi ulnaris 

Palmaris longus to FCU 
insertion 

Sensibility (ring—little) 

Free neurovascular cutaneous 
island flap (in low ulnar palsy) 

Free vascularized nerve graft 
(in high ulnar palsy) 


1 Omer. George E., Jr. 1983. The palsied hand. Ch. 16 in Surgery of the Musculoskeletal System, vol. 1. ed. C. McCollister Evarts. Lon¬ 
don: Churchill Livingstone. 




















176 


ORTHOPEDIC SURGERY IN VIETNAM 


Table 23. —Combined low median-low ulnar palsy 12 


Needed function 

Preferred motor 

Alternate motors 

Thumb adduction (AP) 

Brachioradialis with graft 
between 3rd-4th metacarps 
to abductor tubercle 

1st metacarpal 

Direct insertion, flexor 
digitorum superficialis 
(Brand/Goldner) 

(or) 

Split insertion, flexor 
digitorum superficialis 

Thumb opposition (APB) 

Extensor indicis proprius 

Extensor digiti quinti 
(or) 

Extensor carpi ulnaris 
(or) 

Palmaris longus 

Metacarpal-phalangeal joint 
flexion/interphalangeal joint 
extension (integration of 

MP and IP motion) 

Extensor carpi radialis longus 
(four-tailed graft) to either 
flexor sheath or dorsal 
apparatus 

Brachioradialis 

(or) 

Flexor carpi radialis 
(or) 

Flexor digitorum superficialis 
(Stiles/Bunnell) 

Thumb—index tip pinch 
interosseous) 

Abductor pollicis longus slip to 

1st dorsal interosseous tendon 
(and) 

Arthrodesis MP of thumb 

Extensor pollicis brevis 
(and) 

Arthrodesis MP of thumb 

Metacarpal (palmar) transverse 
arch, and little finger 
adduction 

Extension digiti to proximal 
phalanx (extensor digitorum 
communis to little finger 
must be active) 



1 Omer, George E.. Jr. 1982. Combined nerve palsies. In Green, D. P., ed.: Operative Hand Surgery, New York: Churchill Livingstone. 
: Omer, George E.. Jr. 1983. The palsied hand. In Evarts, C. McCoIlister, ed.: Surgery of the Musculoskeletal System, vol. 1, London: 
Churchill Livingstone. 


Tendon transfers may enhance the rehabilitation of patients with peripheral 
nerve injuries and paralysis of the lower extremity. The successful tendon transfer 
should have only one basic objective, such as eliminating a deforming force that will 
produce further imbalance, replacing a single lost motion, or producing stability. In 
contrast to the upper extremity, in the lower extremity stability against gravity is 
much more important than mobility and range of motion. The best reconstructive 
procedure in many patients with lower extremity nerve loss was an effective ortho¬ 
sis. At Brooke Army Medical Center, electromyograms demonstrated voluntary 
motor unit action potentials following tendon transfer, but full active dorsiflexion 
was rarely restored even following months of reeducation. 

Motor reconstruction should be done before and at the same time as sensory re¬ 
habilitation in the upper extremity, because precise sensibility depends upon total 
extremity homeostasis and activity (Omer 1974b). However, one should not trans¬ 
fer any muscle that has had a functional nerve deficit. 









PERIPHERAL NERVE PROBLEMS 


177 


Table 24. —Combined high median-high ulnar palsy 12 


Needed function 

Preferred motor 

Alternate motors 

Thumb flexion (FPL) 

Extensor indicis proprius to 
flexor pollicis longus 

Tenodesis of FPL at 

MP joint 

Finger flexion (FDP) 

Extensor carpi radialis longus 

Extensor carpi ulnaris 

Thumb adduction (AP) key pinch 

Extensor indicis proprius 


Thumb opposition (APB) 

Extensor digiti quinti 

Extensor pollicis brevis 
(rerouted) 

Thumb stability 

M-P arthrodesis 


Metacarpal-phalangeal joint 
flexion/interphalangeal joint 
extension (finger clawing) 

Extensor carpi ulnaris 
(four-tailed graft) 

Brachioradialis 

(or) 

Parkes’s tenodesis 
(or) 

Extensor carpi radialis longus 
(or) 

Zancolli capsulodesis 

Volar sensibility 

Radial innervated finger 
fillet flap 



1 Omer, George E., Jr. 1982. Combined nerve palsies. In Green, D. P„ ed.: Operative Hand Surgery, New York: Churchill Livingstone. 
3 Omer. George E„ Jr. 1983. The palsied hand. In Evarts, C. McCollister, ed.: Surgery of the Musculoskeletal System, vol. 1, London: 
Churchill Livingstone. 


Table 25. —Combined high median-radial palsy 12 


Needed function 

Preferred motor 

Alternate motors 

Wrist flexion extension 

Wrist arthrodesis 


Index and long finger flexion 
(FDP—I & L) 

Flexor digitorum profundus 
tenodesis 


Finger extension (EDC) and 
thumb extension (EPL) 

Flexor carpi ulnaris 


Thumb opposition (APB) 

Abductor digiti quinti 

Adductor pollicis (abductor 
insertion) 

Thumb flexion (FPL) 

I-P tenodesis 


Thumb stability (APL) 

M-P arthrodesis 

APL tenodesis 


Sensibility (thumb-index) 

Neurovascular cutaneous island 
pedicle from ring finger 



1 Omer George E Jr. 1982 Combined nerve palsies. In Green, D. P„ ed.: Operative Hand Surgery. New York: Churchill Livingstone. 

2 Omer! George E.’, Jr. 1983. The palsied hand. In Evarts, C. McCollister, ed.: Surgery of the Musculoskeletal System, vol. 1, London: 
Churchill Livingstone. 



























178 


ORTHOPEDIC SURGERY IN VIETNAM 


Table 26 .—Combined high ulnar-radial palsy 12 


Needed function 

Preferred motor 

Alternate motors 

Wrist extension (ECRB) 

Pronator teres (yoke to ECRL 
and ECU) 


Wrist flexion (FCU) 

Palmaris longus (to FCU 
(insertion)) 


Finger extension (EDC) and 
thumb extension (EPL) 

Flexor digitorum superficialis 
(long and ring) 


Finger flexion (EDP—ring 
and little) 

Flexor digitorum profundus 
tenodesis 


Proximal thumb stability (APL) 

Flexor carpi radialis 
(yoke insertion) 

APL tenodesis 

Thumb adduction (AP) 

Flexor digitorum superficialis 
(index) 

M-P arthrodesis 

Metacarpal-phalangeal joint 
flexion/interphalangeal joint 
extension (finger clawing) 

Parkes’s tenodesis 

Zancolli capsuloplasty 

Sensibility (ring—little) 

Free neurovascular cutaneous 
island flap 



1 Omer, George E.. Jr. 1982. Combined nerve palsies. In Green. D. P.. ed.: Operative Hand Surgery, New York: Churchill Livingstone. 
Omer, George E„ Jr. 1983. The palsied hand. In Evarts, C. McCollister. ed.: Surgery of the Musculoskeletal System, vol. 1, London: 
Churchill Livingstone. 


Sensory Function 

Major contributions in the evaluation of sensibility, sensibility reeducation, and 
the reconstruction of sensory capabilities were accomplished at Army Medical Cen¬ 
ters during the Vietnam War (Omer 1968; Omer 1971; von Prince and Butler 1970). 
Omer and associates at the Brooke Army Medical Center developed a battery of 
tests for sensibility that was based on the work of von Frey, Weber, Minor, Seddon, 
Tinel, Moberg, Wynn Parry, and others. The test battery was designed to evaluate 
spontaneous recovery of regenerating nerves in the upper extremity, and more than 
26,900 individual tests were performed between 1966 and 1970 at the Brooke Army 
Medical Center (Omer 1980). The minimum test battery included: 

—Light touch two-point discrimination distance or light touch recognition of 
calibrated von Frey monofilaments (fig. 51). 

—Tinel s percussion test, utilizing a tuning fork (40 Hz) for consistent percussion. 

—Dye tests, such as cobalt-chloride, for gross evaluation of sweating as the indi¬ 
cator for sudomotor activity. 

—Electromyography. 

Voluntary muscle contraction test on Highet's scale with measured arc of motion. 

—Gross hand grip in pounds. 












PERIPHERAL NERVE PROBLEMS 


179 



Figure 51.—Application of von Frey monofilament to digit. The digit should be stable, 
and the appropriate pressure of application is demonstrated. 


—Tip and key finger pinch in pounds. 

—Object recognition tests. 

—Timed pick-up test utilizing nine objects. 

This test battery was utilized, with modifications, at all Army Medical Centers 
by the end of the Vietnam War. The occupational therapists and physical therapists, 
who did most of the tedious work, would transfer to other hospitals and initiate new 
programs for sensibility evaluation and education (Werner and Omer 1970; Reid 
1977). Von Prince and Butler (1970) developed the “normal” ranges of light touch 
to deep pressure sensibility as measured by the von Frey hairs; Werner and Omer 
(1970) outlined a technique for measuring sensibility with the two-point discrimina¬ 
tion test and established the timing of the picking-up test with a standard number of 
objects (Omer 1968). 

Raymond M. Curtis, as Consultant in Hand Surgery to the Surgeon General, 
had an active clinical role at Walter Reed Army Medical Center and the Johns 
Hopkins University program. Curtis and associates developed programs for reedu¬ 
cation of sensibility in the hands (Dellon. Curtis, and Edgerton 1971 and 1974). The 
pattern of sensory recovery was mapped at regular intervals, using the following: 

—Recognition of constant and moving touch. 

—Perception of vibration at 30 and 256 Hz by tuning fork. 

—Two-point discrimination distance. 





180 


ORTHOPEDIC SURGERY IN VIETNAM 


Several objects are used for retraining sensibility: 

—Fingertip of normal hand. 

—Pencil eraser or another soft object, for early-phase reeducation. 

—Various sizes of square, hexagonal, and round objects, such as nuts and washers. 

—Keys, coins, safety pins, and similar objects used in daily living, for late-phase 
reeducation. 

Early-phase reeducation is begun over the areas in which no two-point discrimi¬ 
nation has returned, but vibration is perceived. The retraining objects can be either 
a pencil eraser or a fingertip of the normal hand. The patient attempts to perceive 
the constant touch aspect of the object. A retraining session lasts 10 to 15 minutes 
and is done 3 to 5 times a day. The patient observes the object, thinks how it feels, 
turns his head, closes his eyes, and verbalizes the sensibility. Once the constant 
touch is perceived, late-phase reeducation is begun. The patient moves an object 
back and forth between the thumb and fingers in the normal hand, shifts the object 
to the injured hand, and attempts to identify the object with his eyes opened and 
then closed. The improvement in two-point discrimination has remained intact over 
several years (Reid 1977). Reeducation concepts were taken by Curtis’ military Fel¬ 
lows in Hand Surgery to all Army Medical Centers, where the techniques were in 
use during the Vietnam War. 

Surgical procedures to restore sensibility following irreparable nerve damage 
concentrated on replacing precise prehension in upper extremity. The neurovas¬ 
cular island flap was utilized to transfer full-thickness skin and subcutaneous tis¬ 
sue with an intact nerve supply. The operation should be done after indicated 
tendon transfers have been accomplished and the patient has supply tissues with 
an established range of motion for the involved extremity. Omer and associates 
(1970) reported a series of 15 patients with high median palsy treated with neu¬ 
rovascular cutaneous island pedicle flaps. They emphasized that sensibility will 
diminish unless there is normal motor activity for precise prehension. The 
Brooke Army Medical Center team described a double cutaneous island from 
the ring and little finger on a common digital artery-nerve pedicle that provided 
precise sensibility to the volar aspect of the thumb and thumb-index web (fig. 
52) (Omer et al. 1970). Patients with high median palsy and high ulnar palsy lost 
all capacity for precise prehension. In these patients, Omer (1974b) filleted the 
index ray through the proximal second metacarpal. The insensitive skin distal to 
the level of the proximal phalanx of the index finger is discarded. The insensitive 
palmar skin proximal to the index and long fingers is excised. The filleted index 
finger dorsal palmar flap is then fitted into the palmar defect to provide sensa¬ 
tion through the superficial radial nerve. 

Prosthetic devices for patients with sciatic palsy were carefully padded to re¬ 
lieve the sole of the foot from excessive pressure. Well protected feet did not de¬ 
velop ulceration under supervised ambulation. Special shoes were developed to 
avoid localized pressure. Amputation is not indicated in any traumatic nerve 
palsy in the lower extremity unless there is chronic and severe secondary ulcera¬ 
tion and infection. 


PERIPHERAL NERVE PROBLEMS 


181 




Figure 52.—Demonstration of the double neuro-vascular cutaneous island from the 
ring-little web space to innervate the thumb-index web space. Neuro-vascular cuta¬ 
neous island transfer in place. The two cutaneous excisions were from the same pattern, 
so that no additional skin is needed. The ring-little web space no longer has sensation. 





182 


ORTHOPEDIC SURGERY IN VIETNAM 


LONG-TERM FOLLOW-UP OF COMBAT-INCURRED 
PERIPHERAL NERVE INJURIES AT FITZSIMONS 
ARMY MEDICAL CENTER 


Colonel William W. Eversmann, Jr., MC, USA (Ret.) 

A long-term follow-up study of combat-incurred peripheral nerve injuries was 
begun at Fitzsimons Army Medical Center in 1967 by Brown and continued by 
Burkhalter and Eversmann until its termination in 1983. Patients who had incurred 
traumatic peripheral nerve injuries either in the Republic of Vietnam or within the 
local community were registered in this comprehensive study to evaluate the long¬ 
term results of their treatment at Fitzsimons. Over 85 percent of these patients had 
sustained combat-incurred injuries to peripheral nerves during their duty in the Re¬ 
public of Vietnam and had required initial treatment either in the Republic of Viet¬ 
nam or before arriving at Fitzsimons and often both. At Fitzsimons, all had required 
additional surgical treatment involving nerve exploration, which was in most cases 
combined with neurolysis, nerve suture, free nerve graft, or pedicle nerve graft in an 
attempt to restore some neurological function. 

Following surgical treatment, patients were followed at Fitzsimons Army Medical 
Center as long as was feasible. If and when the patient left the immediate area of Den¬ 
ver, Colorado, follow-up was continued through a questionnaire. A standard set of 
questions was developed for each level and type of nerve injury in an attempt to evalu¬ 
ate the patient’s functional capability and neurological result following surgery. A file 
of current addresses was maintained with the help of the Disability Services for Re¬ 
tired Military Members and the Veterans Administration so that the questionnaire 
could be sent to these patients to survey their progress three to four times a year. 

Whenever possible, the patients in this study were invited to return to Fitzsi¬ 
mons Army Medical Center for detailed follow-up evaluation. But they repre¬ 
sented a highly mobile population of young individuals, and relatively few were 
able to do so. Because of the method of follow-up on many long-term patients, a 
detailed quantitative sensory and motor assessment of their condition throughout 
the entire period of the study was not always possible, and a statistically significant 
evaluation of these nerve injuries cannot be formed. Nevertheless, through the 
study of the available records, including hospital summaries, detailed medical eval¬ 
uations of the affected extremities, questionnaires, and, whenever possible, detailed 
long-term follow-up examinations, some information on the long-term results of 
combat-incurred peripheral nerve injuries can be provided. And certain principles 
of treatment that were followed throughout the study can be evaluated by means of 
the patient’s responses to the questionnaire and the follow-up examination of those 
patients who were geographically available. 

Contained within this study group are a total of 681 patients. Among them, 198 
had injuries to the ulnar nerve. An additional 151 suffered damage to the median 
nerve. The radial nerve was injured in 39. One or more digital nerves were involved 
in 93 patients, and the brachial plexus in 17. One hundred thirty-two patients had 
injuries to major peripheral nerves of the lower extremity, either the sciatic nerve, 


PERIPHERAL NERVE PROBLEMS 


183 


the posterior tibial nerve, or the peroneal nerve, and 51 had multiple nerve injuries 
in either the upper or lower extremity, or a combination thereof. 

The following information can be gleaned from this series: Whether external on 
the peripheral nerve, internal using microscopic dissection of the fascicular struc¬ 
ture, or used following saline injection of the epineurium and epineurotomy, neu¬ 
rolysis procedures seem to be generally successful where indicated. Occasionally, a 
well-documented, dramatic response of return of function, including two-point dis¬ 
crimination, was observed. This return of function occurred after neurolysis when 
for weeks or months before surgical exploration no gain of neurological function 
had occurred in the peripheral nerve trunk. In no instance within these 681 patients 
was a postoperative causalgic syndrome created by the neurolysis, although it might 
have been present before neurolysis and recurred afterwards. 

On multiple occasions throughout this study, attempts to integrate electrodiag¬ 
nosis into the surgical procedure in order to identify intact fascicular structure were 
generally unsuccessful except when used to identify motor nerves during surgical 
dissection. Micro-needle electrodiagnostic techniques were not employed in this se¬ 
ries, and macro-techniques did not seem to add significantly to surgical diagnosis, 
intra-operative technique, or additional successful recovery of the peripheral nerve. 

Approximately 15 percent of the patients in this series underwent primary rather 
than secondary repair of peripheral nerves. Many of the primary repair patients were 
suffering from locally generated trauma rather than combat wounds, a fact that might 
have been significant because the injury in these instances was often less severe. But 
although multiple factors may have contributed to the outcome in cases treated pri¬ 
marily with nerve suture, in general these patients apparently responded better to pe¬ 
ripheral nerve suture than did those who underwent secondary neurorrhaphy. 

One method of repair of peripheral nerves that had suffered partial laceration, a 
type of injury commonly found in fragment wounds, consisted of exteriorizing intact 
fascicular structure and simply suturing the divided fascicular structure in a so-called 
loop or D-type of nerve suture. The intact fascicles are allowed to lie relaxed in the ad¬ 
jacent tissue while the divided fascicles are sutured end to end by fascicular suture to 
restore their continuity. The sutured fascicles are generally those that are shorter, and 
thus the intact fascicles form a loop or the rounded portion of a D. In most patients, a 
portion of the peripheral nerve’s function is maintained or returns after injury, but be¬ 
cause of division and scarring of fascicular tissue and the formation of a modified neu¬ 
roma in continuity, full neurological function does not return. In this series, this type of 
peripheral nerve repair did not usually result in loss of neurological function from the 
preoperative state, but it seemed to have no value in restoring additional neurological 
function from the preoperative state. The experience of these patients suggests that a 
loop or D-type of nerve suture may have no value in the secondary treatment of pe¬ 
ripheral nerve lacerations that involve only a portion of the peripheral nerve. 

In a small number of patients, no neurological function returned after an initial 
secondary repair of the peripheral nerve. Some then underwent a second explo¬ 
ration of the peripheral nerve and a repeat secondary neurorrhaphy of the nerve 
after excision of neuroma. As a general rule, the results of a second nerve repair 
were poor, since the nerve suture had to be placed within a bed that was often 
poorly vascularized with dense, deep scar about the nerve repair. Many patients did 
not feel that the results justified the additional operative procedure. One would 


184 


ORTHOPEDIC SURGERY IN VIETNAM 


have to conclude, therefore, that if initial nerve suture was unsuccessful in restoring 
some neurological function, a repeated nerve suture with excision of additional 
neuroma was of very limited value. 

Throughout this study of 198 injuries to the ulnar nerve and 151 to the median 
nerve, the median nerve provided both a higher incidence and a greater degree of 
cold intolerance than either the ulnar or radial nerve. When present, cold intoler¬ 
ance did not decrease with time in patients who were followed ten to twelve years 
after nerve suture, a situation that was particularly true in the median nerve. The 
incidence of cold intolerance was more frequent with the ulnar nerve than the ra¬ 
dial nerve, but the number of cases of radial nerve damage in the series is small 
compared to that of ulnar nerve damage. The incidence of cold intolerance, there¬ 
fore, seems to be related to the greater sensory function of the nerve or to a combi¬ 
nation of sensory function and vascular integrity of the peripheral nerve segment. 

Heroic efforts to bridge major gaps in peripheral nerves by mobilization of the 
nerve several inches proximally or distally generally resulted in poor recovery, pos¬ 
sibly, in part, because of a severely scarred surgical bed in which the nerve lay or, 
conceivably, because of traction on the peripheral nerve with joint mobilization 
postoperatively. In none of the cases did mobilization of the joints of the extremity 
in the postoperative period create a reduced function in the peripheral nerve at the 
time the joints were mobilized. No critical period of mobilization or length of dis¬ 
section of either the proximal or distal stump of the peripheral nerve could be iden¬ 
tified from these data. A few patients, particularly those with injuries to both nerves 
of the forearm, underwent pedicle nerve grafting using the St. Clair Strange tech¬ 
nique, in which, in a series of operations, the ulnar nerve is used as a pedicle graft to 
bridge a gap of the median nerve. This approach created surprisingly useful func¬ 
tion, function that often seemed better than that produced by free nerve grafting to 
the median nerve, particularly when the nerve graft lay in a scarred bed. Although 
the cases of both free nerve grafting and pedicle nerve grafting were few, the gen¬ 
eral impression of the cases treated by these methods is that pedicle nerve grafting 
where appropriate and indicated, using the St. Clair Strange technique, is to be pre¬ 
ferred over free nerve grafting. 

In several well studied cases, repeatedly documented by detailed physician ex¬ 
aminations of the hand, a return of interosseous muscle function and, thus, of in¬ 
trinsic function of the hand was clearly demonstrated more than two years after 
above-elbow suture of the ulnar nerve. The longest documented period before re¬ 
turn was eight years after nerve suture. The patient had been examined in a de¬ 
tailed fashion some six years after nerve suture and found to be without intrinsic 
function. Two years later, however, he had sufficient return of the intrinsic function 
of the hand in the interosseous muscles to reduce a claw deformity of the fingers re¬ 
sulting from ulnar paralysis. At least one patient with an injury at the brachial 
plexus level had a late return of intrinsic function of the hand multiple years after 
injury, although in this case the ulnar nerve may not have been divided. These well 
documented late returns of neurological function to the intrinsic muscles of the 
hand are contrary to all results previously reported in the medical literature. 

Because some 349 patients in this series had either median or ulnar nerve neu¬ 
ropathy, a relatively large number of patients had undergone intrinsic transfers for 
the abductor pollicis brevis because of median nerve injury or to relieve intrinsic 


PERIPHERAL NERVE PROBLEMS 


185 


palsy resulting from ulnar neuropathy. Many of these patients returned for long¬ 
term follow-up 8 to 12 years following their nerve suture and intrinsic transfers. Al¬ 
though a multitude of tendon transfer techniques were used in these patients, a few 
transfers were used more commonly than others and could be followed some 8 to 
12 years after the transfer had been performed. 

The so-called opponens transfer to replace the abductor pollicis brevis used ei¬ 
ther the flexor digitorum superficialis of the ring finger routed with a variety of 
methods to perform opposition of the thumb and replace the abductor pollicis bre¬ 
vis or the extensor indicis proprius routed around the ulnar border of the wrist, 
after the method of Burkhalter (Brown 1969; Burkhalter 1974; Omer 1968). The 
transfer continued to function satisfactorily in patients seen in long-term follow-up 
and to provide excellent positioning of the thumb for grip and grasp. The extensor 
indicis proprius transfer apparently had no significant tendency to lose function by 
stretching out, nor did the flexor digitorum superficialis of the ring finger transfer 
exhibit any apparent significant incidence of loss of extension of the MP joint of the 
thumb with long-term evaluation. As performed by many individual surgeons, both 
transfers continued to maintain an acceptable and even excellent degree of posi¬ 
tioning function for the thumb. 

Tendon transfer to replace intrinsic function lost by ulnar palsy could similarly 
be followed for the long term in this study. The most common transfer performed 
was a power grip transfer using the extensor carpi radialis longus prolonged with a 
tendon graft, passed volar to the transverse metacarpal ligament, and inserted with 
a bony insertion at the proximal phalanx (Burkhalter and Strait 1973). Most pa¬ 
tients found that the goal of the transfer had been reached and that their strength of 
grip had been maintained. Eight to twelve years after nerve suture and tendon 
transfer, they continued to be pleased with the transfer for power grip. A few pa¬ 
tients found that they had increased wrist extension while, at the same time, their 
wrist flexion was limited. The limitation of wrist flexion was not troubling, nor did 
these patients associate any functional deficit with the loss. No examined patient 
who had undergone this tendon transfer had noted any deterioration of hand func¬ 
tion in the several years after the transfer had been performed. 

Because of the wide variation in tendon-transferring techniques for other ten¬ 
don transfers used in these patients, it was not possible to ascribe any other general¬ 
izations to the long-term function of tendon transfers. 

SUMMATION 

George E. Omer ; Jr., M.D. 

Injuries of peripheral nerves were severe complications of the extremity wounds 
incurred in Vietnam. Peripheral nerve injuries provided a major stimulus to im¬ 
prove management of the total extremity. Army surgeons developed clinical and 
electrodiagnostic techniques to evaluate the extent of nerve involvement and the 
potential for spontaneous recovery. Associated painful syndromes were aborted 
with new anesthetic techniques or managed with aggressive surgery and followed 
with intensive functional use. 


186 


ORTHOPEDIC SURGERY IN VIETNAM 


The disrupted peripheral nerve usually had a delayed repair utilizing surgical 
techniques antedating current magnification, instruments, and suture materials. 
Approximately 45 percent of sutured nerves resulted in measurable progressive 
functional return. A few patients demonstrated excellent peripheral nerve regener¬ 
ation, which could be related to the extent of injury, time of nerve repair, age of the 
patient, and surgical expertise in major medical centers. Second nerve repairs and 
free nerve grafts had disappointing clinical results. 

More than half of the disrupted nerves did not regain clinical function and many 
surgical procedures were developed that utilized tendon transfers to enhance reha¬ 
bilitation. The more successful tendon transfers involved the forearm and hand. 
Army surgeons made major contributions in the evaluation of sensibility, sensibility 
reeducation, and the reconstruction of sensory capabilities. Through the experience 
and judgment based on large numbers, principles were developed for the recon¬ 
struction of extremities. 


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-. 1970a. Rehabilitation of bilateral lower extremity amputees. J. Bone Joint 

Surg. 52A:687-700. 

-. 1970b. The time factor in surgery of upper extremity peripheral nerve in¬ 
jury. Clin. Orthop. 68:14-21. 

Burkhalter, W. E. 1974. Early tendon transfer in upper extremity peripheral nerve 
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Burkhalter, W. E., and Strait J. L. 1973. Metacarpophalangeal Flexor replacement 
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Burkhalter, W. E.; Butler, B.; Metz, W.; and Omer, G. E., Jr. 1968. Experiences with 
delayed primary closure of war wounds of the hand in Vietnam. J. Bone Joint 
Surg. 50A:945-54. 

Burkhalter, W. E.; Christensen, R. C.; and Brown, P. W. 1973. Extensor indicis pro- 
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Bzik, K. D., and Bellamy, R. F. 1984. Editorial: a note on combat incurred statistics. 
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Canty, T. J., and Bleck, E. E. 1958. Amputation stump pain. U.S. Armed Forces 
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CINCPAC-2. 1968. Commander in Chief, Pacific. Second CINCPAC Conference 
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Dellon, A. L.; Curtis, R. M.; and Edgerton, M. T. 1971. Reeducation of sensation in 
the hand following nerve injury. Proceedings, Am. Soc. Surg. Hand. J. Bone 
Joint Surg. 53A:813. 

-. 1974. Reeducation of sensation in the hand after nerve injury and repair. 

Plast. Reconstruct. Surg. 53:297-305. 

Ewalt, J. R.; Randell, G. C.; and Morris, H. 1947. The phantom limb. Psychoso¬ 
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Frazier, S. H., and Kalb, L. C. 1970. Psychiatric aspects of pain and the phantom 
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Highet, W. B., and Sanders, F. K. 1943. The effects of stretching nerves after suture. 
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Kline, D. G. 1980. Evaluation of the neuroma in continuity. In Management of pe¬ 
ripheral nerve problems , eds. G. E. Omer, Jr., and M. Spinner, pp. 450-61. 
Philadelphia: W. B. Saunders, Co. 

Kline, D. G., and DeJong, B. R. 1968. Evoked potentials to evaluate peripheral 
nerve injuries. Surg. Gynecol. Obstet. 127:1239-48. 

Lankford, L. L. 1980. Reflex sympathetic dystrophy. In Management of peripheral 
nerve problems , eds. G. E. Omer, Jr., and M. Spinner, pp. 216-44. Philadelphia: 
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Lui, C. T.; Benda, C. E.; and Lewey, F. H. 1948. The tensile strength of human 
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Omer, G. E., Jr. 1968. Evaluation and reconstruction of the forearm and hand after 
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-. 1971. Assessment of peripheral nerve injuries. In Symposium on the hand , 

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-. 1980. Sensory evaluation by the pick-up test. In Nerve repair and regenera¬ 
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Omer, G. E., Jr., and Seymour, D. W. 1969. “A year of trauma at the Brooke Army 
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Omer, G. E., Jr.; Day, D. J.; Ratliff, H.; and Lambert, P. 1970. Neurovascular cuta¬ 
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Omer, G. E., Jr., and Thomas, S. R. 1971. Treatment of causalgia: review of cases at 
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Omer, G. E., Jr., and Thomas, S. T. 1974. The management of chronic pain syn¬ 
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9 


Rehabilitation of the 
Combat-Wounded Amputee 

Colonel Paul W. Brown , MC, USA (Ret.) 

As an enlisted soldier in combat in World War II, I first learned how essential mo¬ 
tivation is to the individuals survival—and to his sanity. As a young medical officer 
during the Korean War, I began to wonder why some severely wounded men recov¬ 
ered so well, while others with the same or lesser injuries did not. The patient’s attitude 
about healing and recovery seemed to have as much influence on his hospital course as 
any of the treatments administered. During the subsequent decade of peacetime or¬ 
thopedic practice, I observed over and over that the patient's motivation, regardless of 
the severity or nature of his ailment, could direct the course of recovery and even 
make the difference between healing and permanent disability. With the Vietnam War 
came my opportunity, as a senior military orthopedist, to apply what experience had 
taught me about the rehabilitation of combat-wounded amputees. 

This chapter on rehabilitation is as much philosophical as historical. While it 
shows how ideas about using patient motivation as a rehabilitative device were de¬ 
veloped and applied to Vietnam casualties at Fitzsimons General Hospital in Den¬ 
ver, Colorado, it also inevitably spills over into matters political, sociological, and 
emotional. It falls short of completely defining the goals and limits of early rehabil¬ 
itation of the severely wounded soldiers because it is limited to the story of some of 
these soldiers in one hospital during a portion of one war. Nevertheless, perhaps 
from their experiences can be learned some lessons useful for the future. 


HISTORICAL BACKGROUND 

When the number of beds and physicians is limited and the influx of acutely 
wounded constant, transfers become inevitable once a hospital is full. During 
World War II, the accepted approach to this problem was to treat the seriously 
wounded casualty in a military hospital up to a certain point and then either to 
transfer him to a veterans’ hospital or to discharge him to civilian life. Thus, if the 
casualty had not obtained “maximum hospital benefits” within a certain period, the 
length of which fluctuated according to the pressure for hospital beds, he was trans¬ 
ferred to a “long-term care facility,” generally a veterans’ hospital. An arbitrary pe¬ 
riod of time rather than the degree of recovery was the determining factor in the 
decision to discharge or transfer a patient. This approach, which reserved military 
hospital beds for more acute rather than protracted care, was, from the administra¬ 
tive viewpoint, both useful and practical. But it could adversely affect rehabilita¬ 
tion, and its effectiveness from an overall medical point of view was debatable. 


190 


ORTHOPEDIC SURGERY IN VIETNAM 


In the five years after World War II and before the outbreak of the Korean War, 
the field of rehabilitative medicine progressed to the point of achieving some re¬ 
spectable status as a medical specialty. But most physiatric methods applied to the 
Korean War casualty were devoted to kinesiology, gait patterns, and occupational 
therapy, with only rudimentary attempts at vocational rehabilitation. Although a 
definite advance, these rehabilitation efforts tended to fragment patient care. Phys¬ 
ical medicine was administered to the patient in special departments and areas, and 
the ward surgeons and nurses were, to a degree, excluded from the process. In some 
military hospitals—Letterman General Hospital in San Francisco for one—a good 
deal of jockeying for control of the patient developed among the chiefs of the de¬ 
partments of physical medicine and the various surgical services. 

During the Korean War, the number of casualties was considerably lower than 
in World War II, but fewer military hospital beds and physicians were available for 
them. When a return to duty or discharge to civilian life could not be effected 
within a prescribed time, the pressure to transfer patients to veterans' hospitals was 
even greater than it had been during World War II. By the early 1950s more Veter¬ 
ans Administration hospitals were in operation than at the end of World War II. 
And the prescribed time before transfer was even shorter than it had been in World 
War II, since using the new Veterans Administration hospitals seemed politically 
and fiscally sounder than enlarging existing military hospitals. 

In both World War II and the Korean conflict, the government management of 
the amputees was direct and simplistic. During the time period allowed for hospi¬ 
talization in Army facilities, the amputation was to be completed, the stump healed 
and fitted with a prosthesis, and the amputee shown the rudiments of gait before his 
discharge to civilian life with some type of disability award. If the stump could not 
be healed or fitted within a “reasonable” time, the amputee was transferred to a 
veterans’ hospital. This uncomplicated approach made sense militarily. Because it 
was standardized and uniform, it also permitted the political system to disentangle 
itself quickly from uncomfortable reminders of the price of war. 

But most medical officers during World War II and the Korean War were frus¬ 
trated by the fact that they could contribute only a small bit to the patient’s recov¬ 
ery before they were required to ship him out to another installation. Although tac¬ 
tical and logistical considerations had rendered this approach to patient care 
unavoidable for most overseas hospitals, every physician in the chain of evacuation 
felt that he had done an incomplete job for the individual patient. The surgeon's 
frustrations were compounded by the knowledge that he would rarely ever learn of 
the ultimate outcome of his cases. 

During the period from the end of the Korean War until the casualties from 
Vietnam first reached embarrassing numbers—roughly from 1953 until 1967—the 
specialty of rehabilitation medicine began to mature. Leaders and innovators in the 
tield were asking the question, “Where does treatment cease and rehabilitation 
start?” The true significance of this basically rhetorical question lay in the implica¬ 
tion that treatment and rehabilitation were indistinguishable parts of one another 
and should not be considered separately. In other words, rehabilitation should start 
immediately as a part of the therapeutic endeavor. 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


191 


EVACUATION POLICIES AND THE PATIENT 
IN THE VIETNAM WAR 

The growing conviction that rehabilitation could not be separated from treat¬ 
ment increased concern about evacuation policies that moved the patient from fa¬ 
cility to facility, undermining the continuity of care that was increasingly seen as 
vital to prompt, successful rehabilitation. Furthermore, a transient commitment to 
the patient, the normal consequence of a lack of continuity of care, quite naturally 
fostered a depersonalization of the patient-doctor contact, a situation that frus¬ 
trated the physician intellectually and sometimes, because of his compassionate 
concern, emotionally. The patient, however, experienced more than mere frustra¬ 
tion; he inevitably felt afraid and abandoned. With each move to a new hospital 
scene, he became more reluctant to commit himself fully to a new doctor-patient re¬ 
lationship. No sooner was he familiar with a team of physicians and nurses and a 
hospital environment than the whole scene and all the characters in it (save the 
principal one—the patient) were changed to another. In the course of this change 
the patient was categorized and often referred to by the nature of his injury, not as 
an individual; he was labeled a “fracture, compound, comminuted of the femur” 
rather than “John Smith, who has a fractured femur.” In the initial phases of treat¬ 
ment, early in the chain of evacuation, he could handle this well enough, but with 
each successive change, the trauma increased. The patient saw quite well that each 
move delayed his recovery rather than expedited it, and he felt strongly that he was 
a pawn in a system. The threat of another move depressed motivation; it tended to 
make patients more passive in their own rehabilitation. Moreover, the shifting 
around often created an attitude of skepticism and cynicism about their govern¬ 
ment's concern for them, since multiple transfers were obviously for the benefit not 
of the patient but of the administrative process. 

Holding and treating patients for a month or more in hospitals in Japan in the 
course of their evacuation from Vietnam probably made a good deal of economic 
sense in terms of utilization of our facilities in Japan. It may also have simplified 
transportation problems, but it most definitely interfered with the continuity of 
care of the patient. Although these hospitals provided excellent and devoted care, 
some of the benefit of the early and effective rehabilitation measures usually 
started there was negated by the interruption of the process resulting from evacua¬ 
tion to the United States and exposure to a new medical scene. For many, therefore, 
the care was neither continuous nor orderly but fragmented and frequently 
changed. Ideally, injuries permitting, the patient should be evacuated as rapidly and 
as safely as possible to a general hospital in the United States and kept there 
throughout all of his remaining treatment and rehabilitation. 

In spite of the recognized disadvantages that resulted from the evacuation poli¬ 
cies followed in the early years of the war, the most profound change in evacuation 
policies during the Vietnam War came only as a result oi the Tet olfensive ot Febru¬ 
ary 1968. The sudden influx of large numbers of casualties forced the abandonment 
of the policy that had permitted casualties from Vietnam to spend weeks to months 
in hospitals in Vietnam, in the Philippines, or in Japan before their evacuation to the 
United States. Hospitals in Southeast Asia and Japan were quickly filled, making it 
necessary to send patients directly from Vietnam to the United States, where a much 


192 


ORTHOPEDIC SURGERY IN VIETNAM 


higher proportion of patients with open wounds, open stumps, and fresh, unhealed 
fractures were being received. As a result, in less than a year the orthopedic census 
at Fitzsimons General Hospital more than tripled to over 900 patients. 

Early evacuation of patients had its drawbacks, however. Some were rushed 
into the evacuation chain before their medical condition could safely permit the ex¬ 
tended trip. Occasionally, patients were damaged, and some experienced severe 
discomfort that might have been avoided had their evacuation been deferred for 
even a few days. The most serious complications were seen in those with respira¬ 
tory difficulties or blood loss problems. Overall, however, considering the great 
pressure for acute care beds in Vietnam, screening for early evacuation was han¬ 
dled efficiently and compassionately. 

As the numbers and ratios of these “early evacuees” increased, so, too, did the 
impression that their rehabilitation progressed both more smoothly and more 
rapidly than that of evacuees retained longer in Southeast Asia. The soldier who ar¬ 
rived in the United States only a week or two after wounding was treated by one 
team throughout most of his healing process without the multiple and sometimes 
prolonged interruptions imposed by transfer to other hospitals. The question was 
not quality of care—the caliber of orthopedic treatment in overseas hospitals was 
equal to that in the United States—but consistency of care, since philosophies and 
methods differed from one hospital staff to another. The patient who started his 
healing process under one system and was then transferred to another had to shift 
gears; momentum, enthusiasm, and motivation were lost, irrespective of the rela¬ 
tive merits of the different systems. 

CARE IN CONUS HOSPITALS 

The mission of the general hospital in the United States was never clearly de¬ 
fined in terms of medical responsibility to the Vietnam casualty. A certain amount 
of planning and administrative effort was put into transforming general hospitals 
into “specialized treatment centers,” which concentrated on particular types of 
wounds and to which orthopedic surgeons with known competence in the relevant 
fields were then assigned. The concept was sound but was never applied effectively 
beyond the assignment of one or two appropriately trained surgeons to each center. 
Generally, further support, either by assigning ancillary personnel or by providing 
special equipment or facilities, was never given. As a result, these centers were suc¬ 
cessful in direct proportion to their chiefs’ abilities to innovate, to scrounge equip¬ 
ment, and to hijack needed specialist personnel from other assignments. The efforts 
expended to make these centers effective detracted significantly from energies that 
would have been better applied to their primary mission. 

The appropriateness of continuing orthopedic and surgical residencies at named 
general hospitals throughout the war was a topic frequently and heatedly debated 
among the chiefs of these programs. The experience in wound management and re¬ 
constructive surgery that young surgeons received in caring for Vietnam wounded 
greatly enriched their training programs and attracted many capable young medical 
officers who might otherwise never have been recruited or retained in the Medical 
Corps. But residency training requirements in the form of children’s orthopedic 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


193 


training, basic science studies, and numerous teaching sessions took the resident 
away from pressing duties involving care of the combat casualty. Despite the resi¬ 
dency problems, the overall gain for the Army and for the individual patient was 
great enough to justify continuation of the residencies. 

The patient was not assured of continuity of care even after he arrived back in 
the United States. The length of hospitalization and the “maximum medical bene¬ 
fits" of the individual casualty fluctuated according to administrative policy, whim, 
physical considerations, staffing patterns, and bed availability. The doctrines of 
World War II and Korea might be applied: if a patient could not be “made well” 
within a specific period of time, his treatment should be interrupted and he should 
be separated from the service and transferred to a Veterans Administration hospi¬ 
tal. When these general policies were indiscriminately applied to individual pa¬ 
tients, both continuity and quality of care usually suffered. Some felt expendable, 
abandoned, or culled, probably with reason. 

Fortunately, most general hospital commanders were physicians before they 
were commanders. As a result, they had the motivation and courage to resist or 
subvert policies that threatened detriment to their patients. Many medical officers 
and hospital commanders found ways to delay transfer of patients to Veterans Ad¬ 
ministration hospitals until they had finished their treatment and rehabilitation. 
Only after hospital beds became scarce did The Surgeon General’s Office begin 
pushing these officers to have patients with an anticipated prolonged hospital stay 
discharged from the military and into a veterans’ hospital. 

The Veterans Administration hospital chosen for the casualty was often the one 
closest to his home, which was not necessarily the facility best equipped to care for 
him. Ironically, many wounded soldiers were sent to veterans' hospitals with no ca¬ 
pability for managing their particular treatment or rehabilitative needs just when 
The Surgeon General was promoting the doctrine of the “whole man” approach to 
medical practice and the assessment of disability. A sound concept, it was generally 
overridden by administrative priorities when military hospital beds were scarce and 
was more assiduously applied to the attainment of disability ratings for retiring per¬ 
sonnel than in treating the war wounded. 

Increasing the pressure upon physicians dealing with Vietnam casualties in 
CONUS hospitals was the grim fact that many casualties who would not have sur¬ 
vived their wounds in previous wars were now reaching the United States alive. 
Their survival, the result of using improved medical techniques, helicopter evacua¬ 
tion, and antibiotics, brought hospitals a proportionately higher number of bilateral 
amputees and men with massive combined injuries than any other conflict. These 
patients would experience a protracted hospitalization and significantly greater re¬ 
habilitative problems. Although the public conscience—and the consciences of the 
physicians caring for Vietnam casualties—could quite easily cope with the occa¬ 
sional mangled soldier, as the numbers of these patients grew and facilities and 
staffing became more strained, attention was focused more sharply on their re¬ 
quirements. When the war in Vietnam began to heat up in 1966 and 1967 and ever 
greater numbers of casualties reached the United States, public discomfort grew, 
and physicians increasingly challenged the quality of their approach to their prob¬ 
lems. Orthopedic surgeons involved in the care of Vietnam wounded in CONUS 
hospitals also wondered whether purely fiscal and economic considerations were 


194 


ORTHOPEDIC SURGERY IN VIETNAM 


dictating too much of the hospitalization policy within the United States. Only a 
few surgeons became political activists—to the detriment of their professional obli¬ 
gations—and only a few narrowly defined their medical commitment to its purely 
technical aspects. But many were increasingly concerned about how well our gov¬ 
ernment was fulfilling its responsibilities to its war wounded, believing that the 
wealthiest nation in the world owed ideal care to men who had been rather indis¬ 
criminately selected to fight for a questionable cause. 


REHABILITATION: THE CHALLENGE 

Converging in the spring of 1968 to effect a significant change in the overall 
medical management of our patients were a growing discontent with the war, a bur¬ 
geoning number of casualties, and a changing attitude toward the rehabilitation of 
the seriously injured soldier. The specialty of rehabilitation had continued to ma¬ 
ture during the quieter early years of the Vietnam War from 1961 through 1967, and 
its concept had been expanded. Social workers, vocational counselors, government 
agencies, business, and industry all became more involved with the transition of the 
wounded and disabled soldier to the status of a wage-earning civilian. Physicians 
were increasingly realizing that the surgical challenge extended farther than the 
bodily healing of damaged patients. But the rising numbers of casualties and the 
political and moral frustrations resulting from the Tet offensive in 1968 forced a 
confrontation with the question of how far the rehabilitative process should be 
taken. When did medical treatment cease? What was our obligation to the casualty 
as a patient, as a man, and as a political creditor? 

Motivation became a major tool in the rehabilitation of the orthopedic patient. 
In their attempts to learn how it could best be used, surgeons gathered to discuss 
psychological abstractions openly and attempted to apply them systematically. For 
orthopedic residents, eager to learn the technicalities of operative techniques of 
their newly chosen specialty, the devotion of time and energy to such discussions 
was particularly unusual. Fortunately, although motivation is an abstract quality, 
difficult to describe, even more difficult to recognize, and impossible to computer¬ 
ize or categorize or write policies on, almost everyone recognized what it was. Ward 
nurses, paramedical personnel, physical therapists, and occupational therapists en¬ 
thusiastically accepted the concept and proved to be innovative in discovering, en¬ 
gendering, and stimulating patient motivation. But how these medical people dis¬ 
charged their responsibilities to the amputee varied greatly, since it was influenced 
by their own definition of responsibility, by their medical philosophy, and, espe¬ 
cially in the Vietnam War, by the politics and morality of the time. 

Successful rehabilitation and good medical management were frequently 
thwarted by the leave granted the wounded soldier to return home as soon after his 
return to the United States as his physical condition allowed. While valid for com¬ 
passionate reasons, it interrupted treatment, often for thirty days or more. The 
poorly adjusted casualty tended to become even more so at home, where he was 
often pampered, spoiled, and lulled into a state of lethargy and dependency—all of 
which worked against our attempts to motivate and rehabilitate. A preferable ap¬ 
proach involved giving shorter periods of leave more frequently and coordinating 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


195 


them with a rehabilitation program, but attempts to do so were often defeated by 
parental and political pressures. 

Patient motivation was most successfully exploited to achieve rehabilitation in 
dealing with the amputee, but the motivational techniques developed with him 
were used with various degrees of success with other types of casualties. The pa¬ 
tient with the shattered femur or mangled hand posed greater reconstructive chal¬ 
lenges to the surgeon, and his hospitalization, frequently protracted as it was by 
multiple operations, problems of infection, and nerve and bone loss, was often 
longer than that of the amputee. Nevertheless, the amputee’s loss was more visible 
to him, to his family, and to society. With the exception of the brain-damaged, the 
cord-injured, or the castrated patient, the amputee’s body image was more altered 
and his emotional stress was greater than for most other war wounded. His conspic¬ 
uous loss made it possible for him to display his disability and to use it to foster his 
dependence. Thus, the poorly motivated amputee tended, or at least was tempted, 
to become a professional cripple—physically, emotionally, and sociologically. 

Understanding the individual patient was necessary to successful use of motiva¬ 
tion in his rehabilitation, whatever his injury. Although the fact that a wound of the 
psyche coexisted with the somatic wound helped explain differing reactions to the 
same type of injury, whether the psychic trauma proved to be significant and lasting 
depended on many things, among them the circumstances of the injury, the patient's 
personality, and the nature of the wound itself. Wounds that caused persistent and 
severe pain noticeably affected the patient’s personality and attitude, but pain and 
impaired function were not the only factors governing a patient’s reaction to his in¬ 
jury. Some wounds have traditionally borne a particular stigma not necessarily pro¬ 
portional to their overall seriousness, and the fear that they have inspired also ad¬ 
versely affected the patient’s motivation. Because different men react so differently 
to pain, fear, and wounding, surgeons encountered varied and often unpredictable 
reactions in amputees from the Vietnam War. The rehabilitation team discovered, 
however, that subjective responses to wounds could become tools for motivation. 

Those who proved capable of managing much of their own rehabilitation dis¬ 
played many diverse qualities, some obvious—among them courage, philosophic 
acceptance, and aggressiveness—and others more subtle including sublimation, 
transference, and overcompensation. The sum total of these reactions, whatever the 
particular mechanism, was adaptation. Those who adapted well needed only medi¬ 
cal technical skills and logistical aid to attain their rehabilitation. The patient who 
was psychically devastated by his wound, regardless of its nature, might remain so 
for long periods or even permanently. These men, a minority of the total, appeared 
to have no reserves or inner strength and responded listlessly, or not at all, to our 
attempts to rehabilitate them. They seemed drained of will and the resolve to im¬ 
prove and almost to welcome a permanent state of disability. They manifested their 
psychic wounding in many different ways, some by chronic depression, some by ap¬ 
athy and listlessness, and some by antisocial behavior. Unsophisticated in the sci¬ 
ence of psychiatry, surgeons classified these reactions as neuroses, a term which, 
even though passe, still proved useful in overall management of these patients. For 
the majority of casualties who fell between the two extremes, recognition that the 
psychic aspects of some wounds required special attention proved useful in facilitat¬ 
ing and accelerating the recovery process. 


196 


ORTHOPEDIC SURGERY IN VIETNAM 


As is so often true in the practice of medicine of any specialty, communication 
and education proved to be most valuable tools, since the patient often had many 
needless misapprehensions about his injury. In these instances, a thorough explana¬ 
tion of the wound and its significance quelled the anxieties and depression that had 
inhibited his contribution to his recovery. Some fears were based on misconceptions 
of future surgical procedures, since terms such as “debridement,” “scar revision,” 
“internal fixation,” and “delayed closure” had no real meaning for many, who were 
inclined to imagine the worst. The amputee was both fearful and ignorant about the 
various types of amputations and prosthetics and their implications for future func¬ 
tional capacity. Most patients were reluctant to admit their ignorance or were inhib¬ 
ited by the disparity in rank between themselves and their surgeons. Thus, although 
most patients quickly acquired a practical education in some of these matters 
through their own observations, experience, and conversations with other patients, 
much of what they learned was based on superstition, misunderstanding, and gossip. 
We deemed it important to establish rapport and to start patient education shortly 
after the patient entered in the hospital. Ward officers were encouraged to start the 
process in the initial interview with the patient and to continue it on ward rounds. 

The approach to education, straightforward and basically simple, had three objec¬ 
tives. The first was identification and analysis of the problem with the patient. The 
aim was a realistic look by the patient and doctor together at the injury and the 
anatomy of the injured part and an explanation of the healing process. The second 
was an examination of the significance of the injury to the patient’s body and to his fu¬ 
ture. This, although usually simple, could be complex because of what the patient had 
already been told and the prejudices and fears that had already become entrenched. 
In spinal cord or pelvis injuries, the probabilities concerning the patient's future sex¬ 
ual capacity had to be addressed. When there were disfiguring wounds, a forecast of 
future appearance was necessary. Amputees required education about their pros¬ 
thetic and functional potential as well as discussion on how they would be received by 
families and society. The third was an indoctrination into the rehabilitation process. 
The patient was shown how he could make a quicker, more comfortable, and more 
satisfactory recovery if he contributed actively to his own progress. The difference be¬ 
tween active and passive participation was made clear. The various types of rehabili¬ 
tation programs, both obligatory and voluntary, in which he would be participating 
were explained as were the interests and identities of the people conducting these 
programs. Great emphasis was placed on progress and on planning for the future. 

The third phase was continued throughout the patient’s hospitalization. Patients 
with similar wounds or problems who were making good progress were often en¬ 
listed as teachers and stimulators. All members of the rehabilitation team—ward 
nurses, corpsmen, technicians, physical and occupational therapists—contributed, 
often with effectiveness and enthusiasm that outstripped that of a physician’s. 
Wives, girl friends, and parents were also helpful if they did not smother the patient 
with sympathy and protection. LJnfortunately, the families of the more passive pa¬ 
tients, those who most needed stimulation, were those most inclined to be overpro- 
tective. With some of these patients, their families emerged as adversaries to the re¬ 
habilitation program and in some instances caused it to fail. 

Some patients preferred discussing their injuries privately with the physician, but 
others were more open and expressive when part of a group discussion. Amputees 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


197 


tended to congregate because of their common problems and their assignment to 
amputee wards, to form their own exclusive fraternity from which medical personnel 
were largely excluded. In day rooms, at the Red Cross, and in local bars, groups 
tended to spring up spontaneously within the amputee society, among patients in 
traction confined for most of their hours to one ward or cubicle, or among men in 
physical therapy. The same was true for hand surgery patients. Some patients of di¬ 
verse wounds, but with common vocational interests, were brought together through 
vocational rehabilitation sessions. In some, race, background, or hobbies was the 
common ground. The commissioned officer patient was sometimes included in 
groups and sometimes excluded from spontaneous and social groups, but no discrim¬ 
ination was made on the basis of rank where groups were formed by the staff. The 
officer patient who was assigned to a group sometimes excluded himself or was re¬ 
jected by the group. He could become a difficult patient to rehabilitate. With these 
few, the bar at the hospital officers' club was often his ally, though seldom his friend. 

Since much of the conversation in the informal groups was based on surmise 
and gossip and might reinforce misinformation, the creation of structured group 
discussions led by someone knowledgeable on the topics was attempted. These 
group sessions were useful in improving both education and communication be¬ 
tween patients and staff. Some patients attended groups but seemed not to partici¬ 
pate, although they might report later that they had achieved a better understand¬ 
ing of their injuries and treatment by their presence at such sessions. Others were 
willing to ask questions while in the group on topics which they were reticent to dis¬ 
cuss alone with their physicians. 

These group encounters were not regarded as “group therapy" sessions but rather 
as a means to better understanding. Members of the psychiatry staff seldom partici¬ 
pated, nor was there need for their participation. Psychiatric attention was, of course, 
occasionally needed by an individual patient, but little relationship could be seen be¬ 
tween the nature of the patient s wounds and the appearance of any overt psychic ab¬ 
normality. Since orthopedic surgeons were usually understaffed and they often had 
difficulty merely in keeping up with the surgical schedule, ward rounds, and the or¬ 
thopedic training program, they tended not to become much involved with the psy¬ 
chodynamics of the rehabilitation process. Yet many orthopedic surgeons perceived, 
if only dimly, that there was more to orthopedic surgery than the surgery itself. 

MOTIVATION AND THE REHABILITATION PROGRAM 

Until the mid-1960s, the approach to wartime amputee care had changed little 
from that of World Wars I and II and the Korean War: heal the stump, fit it with a 
prosthesis, train the patient in its use, and discharge him to civilian life. Although 
advances in prosthetics and orthotics contributed to better function and the addi¬ 
tion of vocational counseling and driver education to some degree rendered the ad¬ 
justment to civilian life easier, progress in programs to help amputees live as normal 
lives as possible had not been significant. All management programs had been di¬ 
rected toward what was lost, not toward what had been retained. Only when the 
number of amputees began climbing rapidly in 1967 were ways explored to expand 
their total rehabilitation, using patient motivation as the key. 


198 


ORTHOPEDIC SURGERY IN VIETNAM 


In its basic form, motivation is a manifestation of a desire for gratification. Some¬ 
times that desire is obvious enough—doing something because it’s fun, it feels good, 
or it wins admiration and recognition. Probably more often the desire is much more 
complex, obscure, or subconscious. Because of the complexity of human emotion and 
behavior, orthopedists have been uncomfortable in speaking, writing, or dealing with 
these mechanisms and have tended to retreat from that poorly defined field to the 
more familiar and comfortable terrain of the operating room, laboratory, and clinic. 
But as the Vietnam War continued, military orthopedists grew progressively less sat¬ 
isfied about the results that they were achieving and. consequently, became increas¬ 
ingly involved in rehabilitation. Recognizing the significance of patient motivation, 
they attempted to stimulate and harness it to their ends and thus found themselves in¬ 
dulging in behavior modification, although they did not recognize it by that name. 
They found themselves involved in trying to get patients to do things that they didn't 
necessarily want to do by making them want to. Once they became consciously aware 
of what they were doing, they found it increasingly easy to devise means to that end. 
In many patients, the process, once started, became self-sustaining, and individual pa¬ 
tients often became contributors to the behavior modification of others. 

The attempt to find enjoyable physical activities that would contribute to pa¬ 
tient rehabilitation, combined with the memory of reports of Austrian skiers who 
had returned to skiing after World War II in spite of amputations, led to the consid¬ 
eration of their sport for Fitzsimons' amputees. Willie Schaeffler, director of the ski 
school at Arapahoe Ski Basin in Colorado, affirmed that a skier who had lost a leg 
could ski, but stressed his belief that skiing would be feasible only for amputees 
who had already learned to walk, who were in excellent physical condition, and 
who had been expert skiers before their amputations. None of the Fitzsimons am¬ 
putees met these criteria, and none were in the least interested in learning to ski. 
Nevertheless, we decided to try it. 

Schaeffler agreed to lend his advice and ski instructors. Larry Jump, the owner 
of Arapahoe Basin, 10,800 feet up in the mountains 75 miles west of Denver, volun¬ 
teered to supply the ski facilities. Special Services buses provided transportation. 
Head Skis donated skis and Cubco and Miller ski bindings. Generous donations 
from Colorado skiers supplemented Special Services ski boots and clothing. Aware 
that in Europe the one-legged skier used one normal ski and two very short skis 
mounted on some type of pole or crutch, the orthopedic brace shop at Fitzsimons 
set to work mounting 17-inch ski tips to Canadian crutches. They devised a mount 
that allowed the ski to tilt back and forth while retaining lateral stability. 

Using a series of ski movies, instructions, and pep talks, Edwin Lucks, one of 
Schaeffler’s senior instructors, began to indoctrinate the Fitzsimons amputees. His 
great enthusiasm and obvious dedication to success created a modest amount of in¬ 
terest in the amputees and produced an agreement that it was at least worth trying. 
The chance discovery a few weeks later that Dr. William F. Stanek. chief of ortho¬ 
pedics at the Denver Children’s Hospital, had been trying to establish such a pro¬ 
gram for juvenile amputees for several years but had been unable to obtain much 
support for it, led to an agreement to join forces. 

On the cold and snowy morning of 10 January 1968, twenty military and eigh¬ 
teen amputee youngsters, aged eight to seventeen, assembled on the slopes of Ara¬ 
pahoe Mountain. Assisting the amputees were numerous volunteer helpers, among 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


199 


them Red Cross personnel, physical therapists, medical corpsmen, and four be¬ 
mused and somewhat apprehensive ski instructors who, having practiced skiing on 
one ski, were determined to remain on one ski throughout the day. The amputee ski 
program had been born (fig. 53). 



Figure 53. —The start of the amputee ski program: Vietnam amputees and ski instruc¬ 
tors, Arapahoe Basin, Colorado, 10 January 1968. 


The key to confidence in downhill skiing is control of direction and speed, which 
are obtained by the ability to change direction at will, which, in turn, is controlled 
either by torque applied to the long axis of the ski or by twist or cant of the ski, or 
by a combination of both. Cant, or edging, is the angle at which the edges of the skis 
are applied to the surface of the snow. The preliminary maneuver essential to the 
application of torque and edging is weighting and unweighting of the ski. There¬ 
fore, after learning to stand on the one long ski and to use the crutch outrigger ski 
for balance and support, the amputee learned to hop and change direction of the 
long ski by weighting and unweighting it, starting with a slight crouch followed by a 
quick knee and elbow extension and a twist of the trunk. Although many normal 
skiers take several seasons of ski instruction before they master such essentials, 
most amputees learned them in a lesson or two and some seemingly immediately, in 
the first morning on the slope (fig. 54). 

As soon as the amputee had learned to change the direction of his ski, he had 
enough confidence to attempt gliding down the beginners’ slope. Most conquered it by 
the end of the first day and were then eager for something more challenging. Having 






200 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 54. —Three-track skiers. Below-knee 
and above-knee amputees on skis. 


discovered the fun and exhilaration of skiing during the first few runs on the begin¬ 
ners’ slope, few amputees wished to quit. By the end of the day all of the amputee 
skiers were gliding down the beginners' slopes and using the rope tow lift. Learning to 
get on and off the chair lifts presented no more problem for the amputee skier than for 
any other skier; if anything, dismounting from the moving chair was made easier by 
the outrigger skis which allowed better immediate stability and balance than for the 
skier with two skis. Amputee skiers experienced few falls at either end of the chair lift. 
Mistakes and falls on the slopes were numerous, but high spirits and good humor pre¬ 
vailed, and most patients were convinced that skiing was not only possible but fun. 

On the first day, the instructors and their students also began to discover skiing 
and teaching techniques that they continued to develop throughout the rest of that 
winter. The short-ski crutch outrigger worked fine in gliding downhill but proved to 
be of no help in climbing or walking on the level. A spring-loaded “snow spike” was 
therefore developed which would be extruded through the bottom of the outrigger 
ski for walking and could be retracted for gliding downhill. 

Every week thereafter for that first winter, a busload of military and juvenile 
amputees and volunteers met at Araphoe Basin. For most, the rate of progress ex¬ 
ceeded expectations, although a few passive patients quit after the first attempt and 
could not be induced to continue. By the end of the second session, having learned 
to negotiate the chair lifts, a few were skiing on intermediate slopes. By the end of 
the ski season, these few aggressive ones—all below-knee amputees—were skiing 
on expert slopes with skill and grace. Most took four or five days of lessons before 
they learned to handle chair lifts and intermediate trails. 

Most of the amputee skiers had lost one lower extremity, and these, whether the 
loss was below-knee or above-knee, learned to ski with relative ease. Many of 
them, as well as other skiers and ski instructors, thought that learning to ski actually 
seemed to be quicker and easier for the one-legged skier than for the skier with two 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


201 


legs. The upper extremity amputee experienced much greater difficulty. He still had 
the problem of learning to control two skis but could usually use only one ski pole 
and thus had much more difficulty with control and balance. Moreover, receiving 
his prosthesis seldom made skiing any easier. Those who continued skiing chose to 
use only one ski pole. 

Initially, only amputees with healed stumps and in otherwise healthy condition 
were allowed to participate. As the program became popular and proved safe, how¬ 
ever, many amputees with unhealed stumps joined and in numerous instances were 
skiing well before being fitted with a prosthesis. In a sense, they learned to ski be¬ 
fore they learned to walk. There were many falls, few accidents, and only one in¬ 
jury. This last was a fractured tibia incurred by a below-knee amputee who became 
so enthusiastic about skiing that he tried ski jumping. The fracture was treated with 
a long leg walking cast that he was still wearing when fitted with his first prosthesis. 
He returned to skiing the following year. 

Many amputee patients were recovering from multiple wounds, and all, of 
course, suffered from various degrees of depression because of their disabilities. 
The ski slopes developed into a great therapeutic atmosphere in which physical dis¬ 
ability was looked upon only as a challenge and for which the mountain air, the ex¬ 
hilaration of skiing, and the magnificent mountain scenery were catalysts. The rela¬ 
tionship between the soldiers and the children was mutually supportive. The 
children were excited over their association with warriors, all of whom they saw as 
heroes. The soldiers were flattered to be so admired and, at the same time, deter¬ 
mined that the children would not outperform them. A fine sense of symbiotic ca¬ 
maraderie developed between these two groups. 

As the program enlarged and its success became apparent, press coverage was 
quickly expanded. Although the publicity brought beneficial contributions of 
equipment, it also brought problems. Volunteers sprang up from everywhere, some 
sincere in their desire to help, some seeking publicity, and some simply troublesome 
do-gooders wishing principally to gratify themselves. Many agencies and individu¬ 
als praised the program, although some condemned it as cruel and inhumane. The 
orthopedic consultant for The Surgeon General's Office stated that it was inappro¬ 
priate to the mission of an Army hospital and implied that time should be spent on 
other and “better” projects. With all the publicity over the amputee skiing, it prob¬ 
ably did seem that it was an elaborate and time-consuming project, but in fact it was 
not. The use of funds and military personnel was extremely modest; private groups 
and individuals donated most of the equipment and provided most of the assistance 
on the slopes. Several military orthopedic services—notably in the Navy—also an¬ 
nounced that it was dangerous and an inappropriate military endeavor. The charge 
was made that such programs tended to foster and prolong the inclination of am¬ 
putees to rely exclusively on one another for companionship, thus serving as a de¬ 
terrent rather than an aid to rehabilitation. 

In that first year, several bilateral lower extremity amputees insisted on accom¬ 
panying the skiers to Arapahoe Basin. We tried to accommodate them, but 
wheelchairs and snow proved incompatible. Some persisted, however, and de¬ 
manded their share of winter sports. They tried rubber tire tubes tethered by a rope 
controlled by an instructor, an experiment that proved to be both exhausting and 
dangerous. They then started on ski sleds which could be controlled by shifting 


202 


ORTHOPEDIC SURGERY IN VIETNAM 


body weight. But getting these patients and their sleds on and off chair lifts proved 
difficult, and the sleds, which developed considerable momentum and easily went 
out of control, were dangerous. After the first year, these too were abandoned. 

At the beginning of the second winter. December 1968. however, one combined 
above-knee and below-knee amputee was so insistent that the possibilities of skiing 
were explored for him. Lucks, the instructor, fitted with bilateral double upright 
braces with locked knees and ankles, was able to demonstrate that controlled skiing 
was possible using only hip and trunk control. The amputee was then fitted with a 
type of stubby prosthesis for each lower extremity, and in these he learned to ski 
(Brown 1970). Enthusiastic about his skiing, in his first season he learned to ski on 
expert trails and even participated in slalom and downhill races. Mounting and dis¬ 
mounting the chair lift with rigid knees and ankles required courage and agility, but 
he managed and soon was able to accomplish this without interruption of the lift 
operation. Several other bilateral amputees, all above-knee amputees, learned to 
ski in the same fashion, and most did better on skis than they did with ambulation 
in their "normal" above-knee prostheses (fig. 55). 

Great courage and determination were required for a man with no legs to learn to ski. 
Those who succeeded truly were highly motivated. But they were also highly rewarded. 

The amputee ski program at Fitzsimons continued for five seasons. Many physi¬ 
cians. ski professionals, and amputees from all over the E'nited States visited the 



Figure 55. —Who needs knees? On the right, a bilateral above-knee amputee skier on 
stubb\ prostheses. The ski instructor to his left is wearing lons-les braces with 
locked knees, demonstrating that it is possible to ski with onlv hip control w hen knees 
and ankles are rigid, or absent. 





REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


203 


program and applied what they had learned to their own ski areas. Orthopedists, 
too, learned from them, and though a healthy rivalry developed, there was a gener¬ 
ous exchange of information and helpful suggestions. Amputee skiing was started 
in several parts of the United States at about the same time as in Colorado, some in 
conjunction with military hospitals and some under civilian auspices. The answer to 
the question of which ski program for amputees was the first to be established in 
this country is not known. Nor is it particularly important. 

Some ski instructors who started in the Fitzsimons program have devoted much 
of their subsequent skiing careers to teaching handicapped skiers and developing 
new techniques for them. The work of Edwin Lucks has been outstanding in this 
field. Lucks has successfully developed skiing methods for the blind and for people 
with many kinds of physical disability. 

The program was discontinued during the winter of 1973 when the last of the 
Vietnam amputees was discharged from Fitzsimons. The Children’s Hospital pro¬ 
gram moved to another ski area and continued to teach amputees of all ages to ski. 
A total of 400 amputees learned to ski in the Fitzsimons program, and many contin¬ 
ued to ski with pleasure, pride, and proficiency, often participating in ski racing and 
demonstrations and encouraging and even teaching other amputees to ski. 

The primary objective of the program, however, was not to make skiers of am¬ 
putees but to aid disabled patients to accomplish something that would help restore 
their pride and confidence. It was a tool to stimulate motivation to adapt and suc¬ 
ceed. Many of the amputee skiers observed that, after having learned to ski. they 
looked upon themselves not as crippled but rather as merely “inconvenienced.” 

Skiing was not the only sport used as part of the rehabilitation program. As the 
winter of 1967-68 turned to spring and the snow in the mountains began to retreat, the 
orthopedic staff in Fitzsimons, impressed by the accomplishments of their patients on 
the ski slopes, looked for other means to stimulate motivation. With the help of Red 
Cross personnel, a swimming, water safety, and scuba diving course was started in the 
large indoor Special Services pool on the hospital grounds. In this program, many pa¬ 
tients convalescent from trunk and extremity injuries learned to swim or were enabled 
to return to swimming and underwater swimming. This achievement helped motivate 
the patient to participate in his own rehabilitation in the same manner as did skiing. 

The most notable early success with this pool therapy was with the first bilateral 
amputee skier. After he modified the bottom half of a wet suit to conform to his 
stumps and affixed swim fins to it, he was taught to swim and to scuba dive. A triple 
amputee—upper extremity above the elbow, bilateral lower extremity above the 
knee—learned to swim and was then instrumental in enticing a second triple amputee 
with the same combination of extremity loss to learn. In each instance, this accom¬ 
plishment helped considerably in improving morale, body image, and motivation to do 
other things. The swimming was good exercise and, once again, the sense of accom¬ 
plishment helped keep the patient from thinking of himself as a “cripple” (fig. 56). 

The use of the pool for patients with pelvic and lower extremity injuries was ex¬ 
tremely helpful in starting early ambulation. Buoyancy of the body with lightened 
load on healing fractures and damaged joints allowed exercise, weightbearing, and 
early gait training, often months before they would otherwise have been possible. 

Most patients were motivated to use the pool for their rehabilitation, but some 
were afraid of the water and required considerable encouragement to start. Pa- 


204 


ORTHOPEDIC SURGERY IN VIETNAM 



Figure 56.—Bilateral above-knee amputee 
with improvised swim fins. He was also the first 
bilateral above-knee amputee to learn to ski. 


tients who had benefited from the pool and who were enjoying it were the best aids 
to motivating the timid. Occasionally the program was made obligatory for the 
more passive ones for whom persuasion was not enough, but this move was rarely 
successful. One cannot order someone to be motivated; the motivation must be 
stimulated, not commanded. 

A third rehabilitation program was initiated by a Fitzsimons social worker, 
Mary Woolverton, who lived near Denver on a small ranch where she raised Mor¬ 
gan horses. An expert skier and equestrienne, she had much contact with amputees 
and other war wounded and their families in the course of her social work at the 
hospital. As the first amputee ski season came to a halt in April 1968, she enticed a 
few of the amputees to ride one of her even-tempered Morgans. They did so well 
that she was encouraged to start a regular riding program at Fitzsimons for any am¬ 
putees or other patients deemed fit enough. Once a week Mary brought two of her 
horses to the hospital parade grounds and instructed orthopedic patients in the fun¬ 
damentals of horsemanship, including saddling, mounting, riding, and grooming. 

The first pupils were several below-knee amputees who had little difficulty in 
learning to mount, sit, and ride the horse at a walk. They were soon joined by 
above-knee amputees, and they, too, learned to ride, although balance and control 
were a bit more difficult for them. As still more amputees joined in and became 
adept at riding, they became enthusiastic boosters of the program and encouraged 
others to participate. When two bilateral above-knee amputees asked to learn, we 
started them in spite of our misgivings. We boosted them from their wheelchairs 
into the saddle and used a safety strap about their waists to hold them to the saddle. 
Easily learning to ride at a walk, they progressed to a trot and then to a canter in 
the first day. After a few sessions, they were riding at a gallop, whooping in triumph 
at their accomplishment. They were very proud of this—one told me, “Colonel, 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


205 


when I m in this saddle, I m taller than you are.” This first group was then joined by 
many other patients with many combinations of injuries, some with unhealed 
stumps and open wounds and some with an extremity in a plaster cast. Once they 
became contident ot their ability, most disdained use of the safety strap (fig. 57). 



Figure 57. — Triple amputee in the 
saddle. Note the “holsters” for his 
thigh stumps. 


One of the most remarkable riders was the triple amputee who had learned to 
swim. In addition to bilateral above-knee and left above-elbow amputations, this 
young man had a stiff right elbow and only one eye. He not only learned to ride, but 
insisted on learning to pull himself into the saddle from his wheelchair. Determined 
to become an expert horseman, he added trick riding and roping to his repertoire as 
he progressed. The saddle “holsters” devised at his suggestion for his above-knee 
stumps assisted him in maintaining a more stable and secure seat in the saddle. 

Another highly motivated young man had had bilateral hip disarticulations; he, 
too, learned to ride. At first his saddle was built up with pads and pillows, but he 
eventually dispensed with these trappings and used an ordinary western saddle. Al¬ 
though he lacked any means of gripping the horse, and therefore was never really 
secure, he became an excellent rider. He and several other bilateral lower extremity 
amputees gave exhibitions of riding and roping at many horse shows and rodeos. 

A bilateral above-knee amputee who was also blind was taught to ride. Al¬ 
though initially withdrawn and depressed, this patient learned to trot on a horse 
and to lead his mount by verbal guidance from an accompanying rider. He was 


206 


ORTHOPEDIC SURGERY IN VIETNAM 


never a great success as a rider, but he commented that the ability to mount, sit, and 
trot a horse was the only part of his rehabilitation program that gave him any real 
encouragement to face the future. Although far from a typical rehabilitative chal¬ 
lenge, he demonstrated the point about latent motivation. 

The amputee riders formed a riding group which participated in competitive 
trail rides and mountain pack trips. Competing against professional riders, they en¬ 
tered and won many trophies in riding contests. Several now make their living with 
horses, most notably the triple amputee, who runs his own 3,000-acre ranch and 
raises and shows quarter horses (fig. 58). 



Figure 58.—Two amputees at a gallop on the parade ground at Fitzsimons Army Hos¬ 
pital, July 1968. On the left, a triple amputee (bilateral above-knee plus loss of left 
arm). On the right, a bilateral above-knee amputee wearing a plaster cast for gunshot 
fractures of his left upper extremity. 


Programs in golfing, dancing, fishing, bowling, and water skiing were also orga¬ 
nized by many Fitzsimons personnel who volunteered their free time. Many of the 
activities were conceived and organized by the patients themselves. Although for 
obvious reasons bicycling was never popular with the amputees, two below-knee 
amputees became adept on a tandem bicycle. Many further extended their activities 
beyond what might seem to be reasonable limits. Several took up skydiving. One 
bilateral below-knee amputee parachuted regularly wearing his prostheses and also 
enjoyed mountaineering and rock climbing. 






REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


207 


All these activities had their recreational aspects, but recreation was considered 
as only an extra enticement to stimulate the patient to push himself beyond what he 
might have considered his limits. Once started, most of these patients sustained 
their own momentum toward rehabilitation. 


LESSONS LEARNED AND RECOMMENDATIONS 

The complex and pressing rehabilitative needs of the hundreds of amputees hospi¬ 
talized at Fitzsimons General Hospital led physicians to devote much thought to moti¬ 
vation. This chapter describes the concepts and techniques developed at Fitzsimons in 
greater detail for the amputee patient than for other types of war wounded, but they 
are equally applicable to most other patients, regardless of the nature of their wounds. 
We discovered in dealing with amputees that, as far as levels of motivation were con¬ 
cerned, our patients fit the usual bell-shaped distribution curve, a fact that is much 
clearer in retrospect than it was at the time. At one extreme were the few so highly 
motivated to succeed that they did not really need medical personnel to stimulate 
them. Given the necessary technical support, they would have rehabilitated them¬ 
selves without our efforts. At the other extreme was that minority of men who were by 
nature nonachievers on whom our efforts were mostly wasted, men who almost willed 
themselves to become permanently disabled, both physically and mentally. 

Without motivation, the seriously wounded person will not thrive. Low levels of 
motivation will produce only mediocre levels of recovery, at least in the functional 
sense. The patient with motivation in abundance, the doer, the achiever—or the in¬ 
dividual who can be stimulated to be an achiever—will not only cope with his injury 
and recover faster but may also overcome during his rehabilitation almost any 
physical loss his injuries have imposed on him. And since every patient has at least 
some potential for motivation that can be stimulated to develop and then used in 
his behalf, those responsible for rehabilitation found recognizing, encouraging, en¬ 
hancing, and exploiting patients’ motivation potential a real challenge. 

The patients who fell between these two extremes would heal, would cope with 
disability, and would become functional, but would do it better if the surgeon found 
ways to increase their motivation. Many techniques were used. Some patients re¬ 
sponded better to the carrot than to the stick; some needed praise, some bullying. 
Reward, punishment, cajolery, praise, and constant encouragement were all useful. 
Our objective was to have the patient develop pride in achievement, to participate 
in his own recovery, to heal his injuries, and, if not to surmount his disability, then at 
least to succeed in achieving rehabilitation goals despite that disability. 

The key to making the greatest use possible of the patient s potential for motiva¬ 
tion proved to be communication between surgeon and patient. Free communica¬ 
tion—a clear explanation of what was wrong with the patient, what he could expect, 
when he could expect it, and how his own efforts could contribute to his own recov¬ 
ery —increased the patient s confidence in his physician and served as a stimulus moti¬ 
vating him toward recovery. But to communicate successfully, the physician had to 
know the patient, his personality traits, his courage, his drive, and his degree of perse¬ 
verance. In establishing a successful relationship with his patient, the surgeon also 
learned how to recruit and use allies. The ward nurse, the orderly, the physical thera- 


208 


ORTHOPEDIC SURGERY IN VIETNAM 


pist, the occupational therapist (in CONUS), other patients, and the patient s family all 
shared in the effort to encourage the patient to participate in his own recovery process. 

The role of motivation in the recovery process must also be better understood 
and exploited. Achieving these goals will require theoretical and practical research 
into the genesis of motivation and a better understanding of behavior modification 
as applied to returning the wounded soldier to further duty or to a productive civil¬ 
ian role. Our crudely effective attempts at Fitzsimons originated with the managing 
physician, the military surgeon. Perhaps ways in which these goals could be more 
effectively attained would be revealed by a better analysis and structuring of our 
aims and efforts by psychiatrists and psychologists. Such an investigation should 
start in peacetime; it is too easily relegated to the realm of the theoretical or the 
“nice to have but not necessary” category when the shooting begins. 

The Vietnam War was the first war in history in which the lessons learned about 
wound management in earlier conflicts were promptly applied from the beginning. 
This, of course, resulted in the salvage of many lives and extremities which would 
otherwise have been lost to gas gangrene and other infections, vascular insuffi¬ 
ciency, and shock. But the Vietnam War also perpetuated mistakes of policy and 
omission characteristic of the management of patients in earlier wars, mistakes that 
undermined patient morale and sabotaged rehabilitation efforts. A number of rec¬ 
ommendations should therefore be made concerning the management of the medi¬ 
cal aspects of the next war—if the next war should be of a nature to permit the sal¬ 
vage and rehabilitation of the seriously injured casualty. Rehabilitation goals and 
responsibilities for both the military medical establishment and the Veterans Ad¬ 
ministration should be defined. A clearer delineation of the mission of military and 
government medicine is needed, as is a forthright statement—never popular in ei¬ 
ther political or bureaucratic circles—of responsibility for specific levels of rehabili¬ 
tation in the psychologic, vocational, functional, and anatomic sense. In short, the 
mission of each type of hospital should be defined in terms of who does what to 
whom and with what ultimate goal. The closer to the tactical situation the hospital 
is, the simpler this definition will be. Conversely, the more removed from the scene 
of wounding, the more difficult and the more important it is that the hospital’s role 
in rehabilitation be stated, defined, staffed, and planned. 

Although the primary responsibilities of the medical personnel in forward in¬ 
stallations will always be preservation of life, support of vital functions, and saving 
of tissue, all military medical echelons should be indoctrinated in established reha¬ 
bilitative goals. Because the difficulty and the importance of defining and delegat¬ 
ing rehabilitative goals and responsibilities increases with the distance from the 
scene of injury, the goals that must be achieved to return wounded soldiers to pro¬ 
ductive function should be publicized throughout both the military and civilian 
populace, including the political. As a part of this program, there should be a cor¬ 
relative and coordinative effort between military rehabilitation centers and the 
business and industrial complex. 

A mobile consultant in each of the major medical specialties should be desig¬ 
nated. This assignment should be viewed as clinical rather than administrative. His 
duties should include frequent inspections of the chain of evacuation. He should 
have the authority to effect changes in evacuation policies, although he would, of 
course, have to coordinate his efforts with the medical regulating officer of The 


REHABILITATION OF THE COMBAT-WOUNDED AMPUTEE 


209 


Surgeon General's Office according to bed availability and other practical consider¬ 
ations. The situation that arose during the Vietnam War, when the orthopedic con¬ 
sultant to The Surgeon General was the chief of orthopedics at Walter Reed Gen¬ 
eral Hospital and could not both discharge his varied responsibilities at Walter 
Reed and be attentive and reactive to orthopedic problems throughout the Army, 
should not be permitted to recur. 

The chain of evacuation of patients should be reexamined and greater impor¬ 
tance given to ultimate patient outcome in the location and staffing of medical in¬ 
stallations. Although factors such as distance and the availability of medical facili¬ 
ties and personnel cannot be known in advance of a future conflict, given this 
country's total capability, such factors should not be permitted to play as great a 
role as they did in the Vietnam War, when patient outcome was badly slighted. Mul¬ 
tiple transfers should be avoided. Specialized treatment centers should be estab¬ 
lished, staffed, and supported to accomplish their clearly defined missions, and the 
patient moved as quickly as his physical condition permits to a definitive hospital 
for the major portion of his treatment and recovery. 

The role of Veterans Administration hospitals must be better defined. When 
designated as specialized treatment centers, they must be staffed and supported ac¬ 
cordingly. Transfer of casualties to the Veterans Administration system should not 
inflict financial or retirement penalties on the wounded man. 

We must examine the role of surgical residency programs during wartime, bal¬ 
ancing their advantages and disadvantages to both the individual patient and the 
Medical Corps as a whole. Modifications of residency training may be necessary, and 
a better liaison with the surgical specialty accreditation boards would be in order. 

Hospital commanders should be charged with the indoctrination of all medical 
officers in their hospitals in rehabilitative responsibilities and in the need for com¬ 
munication between physician and patient to improve patient education and orien¬ 
tation about his injury and its prognosis for functional recovery. The entire hospital 
must be geared to this effort, not merely the orthopedic service, as was generally 
the case during the Korean and Vietnam Wars. 

Leave policies for the convalescent patient should be tailored to his rehabilitative 
program and progress; hospital commanders should be given relative immunity from 
congressional pressure to implement this policy. Periods of home leave of more than 
two weeks should be discouraged except for exceptional reasons of compassion. 

The recreational rehabilitative techniques developed during the Vietnam War 
should be examined, improved, enlarged, and implemented. Rehabilitation teams 
of surgeons, psychiatrists, vocational guidance counselors, and, in some instances, 
members of the patient’s family could be formed to stimulate and catalyze the pa¬ 
tient's return to useful function. Sound medical care combined with good doctor-pa¬ 
tient communication and an overall interest by our government in the ultimate out¬ 
come would serve to motivate the majority of war wounded to make the most of 
what the vagaries of war have left to them. 

REFERENCE 

Brown, P. W. 1970. Rehabilitation of bilateral lower-extremity amputees. J. Bone 

Joint Surg. 52:687-700. 

















































■ 

























10 


Epilogue 

General Thoughts on the 
Management of Orthopedic Casualties 


Colonel William E. Burkhalter, MC, USA (Ret.) 


LESSONS LEARNED AND UNLEARNED 

In the Vietnam War, perhaps as in no other conflict, wound exploration, debride¬ 
ment, and avoidance of primary closure became the uniform approach to wound 
management. As a result, the infection rate was low and cases of gas gangrene few. 
Staffing the first hospitals deployed to Vietnam by Regular Army officers with some 
experience or training in the management of combat casualties was a major factor in 
eliminating any need to relearn, once again, forgotten lessons from previous wars 
concerning wound debridement and the necessity for leaving wounds open to drain. 

Debridement as an operative procedure was not easily learned, however. The 
surgeon had to have the courage to make the liberal longitudinal incisions and the 
wide excisions of the fascia necessary to expose muscular compartments as well as 
an intimate knowledge of anatomy so that he would not damage undamaged struc¬ 
tures. Although his lack of experience in wound debridement might have resulted 
in a less than optimally debrided wound, delayed primary closure allowed surgeons 
to reexamine and redebride the wound in a few days, thus avoiding the problems of 
frank sepsis with secondary tissue loss. 

An integral part of appropriate debridement is fasciotomy or fasciectomy. Fas- 
ciotomy may involve the investing fascia of the foot, leg, thigh, forearm, or intrinsic 
muscles of the hand. It allows exposure of muscle compartments with their subse¬ 
quent decompression. The injuries resulting from certain high-velocity missiles re¬ 
quired extensive exploration and decompression of all muscle compartments to 
protect the muscles and adjacent nerves from increased compartmental pressure 
and relative ischemia. Similar elevated compartment pressures might follow venous 
injury, especially injury to the popliteal vein, or a delay in vascular repairs proximal 
to the compartment, or crush injuries of the extremity. Fasciotomy in these cases 
was in some instances limb-saving. 

The need for careful debridement was not eliminated by the antibiotics univer¬ 
sally used after wounding in Vietnam. Penicillin, alone or in combination with strep¬ 
tomycin or chloramphenicol, was the usual agent. It was administered, usually intra¬ 
venously, for three to five days in uncomplicated cases or for as long as several weeks 
in more complicated ones. Our concern about managing gram-positive organisms 


212 


ORTHOPEDIC SURGERY IN VIETNAM 


may have caused some of our difficulty with gram-negative infections in offshore 
hospitals. The use of penicillin alone in orthopedic casualties without gastrointesti¬ 
nal soilage seemed to avoid those superinfection gram-negative problems; it pro¬ 
tected against Clostridia and beta-hemolytic streptococcal infection. As the war pro¬ 
gressed, the initial antibiotic treatments seemed useful, but we learned that repeated 
cultures should be used in deciding which specific antibiotics to use. Prolonged treat¬ 
ment, however, was unnecessary and frequently the source of problems. 

As the war proceeded, the emphasis shifted from concern about type and duration 
of antibiotic to concern about individual wound management and the adequacy of in¬ 
dividual debridements. In spite of the use of antibiotics, attempts to use delayed pri¬ 
mary wound closure in all wounds in Vietnam produced some disastrous results. De¬ 
layed primary closure had been emphasized during World War II and the Korean War, 
when it was commonly used in extremity wounds, including those injuries with associ¬ 
ated fractures and joint injuries. But wounds created by the high-velocity missiles fired 
in Vietnam often resulted in considerable tissue disruption. The temporary and per¬ 
manent cavity phenomenon in the limb was well known, and debridement of damaged 
tissue created a larger permanent cavity within the extremity. In the femoral shaft frac¬ 
ture, skeletal traction maintained the dead space in the thigh. Under these circum¬ 
stances, wound closure and minimal drainage created the milieu for wound break¬ 
down. Attempts at delayed primary closure in high-velocity wounds of the thigh were 
fraught with an extremely high complication rate. Attempts to perform delayed pri¬ 
mary closure on injuries of the leg with associated fracture of the tibia also resulted in 
wound breakdown. The skin of the anterior aspect of the leg tolerates tension poorly. 
With minimal skin loss and swelling secondary to fracture, tension closures were com¬ 
mon. The skin responded with necrosis and subsequent sepsis. Relaxing incisions were 
also associated with considerable skin breakdown and subsequent tissue loss. 

As a result, surgeons managing patients in the offshore hospitals and in CONUS 
(continental United States) became disenchanted with the technique of delayed pri¬ 
mary closure in high-velocity wounds of the extremity. They realized that, even though 
several operative procedures had been performed to ensure adequate debridement, 
wound closure was not a mandatory next step. When wounds were encased in air-occlu¬ 
sive dressings and both drainage and antibiotics were recognized as necessary compo¬ 
nents of therapy, closure became an elective procedure that could be performed when 
and if the surgeon concluded that it was indicated, rather than at any specific time. 

Largely because of Dehne s teaching that function aids wound healing and frac¬ 
ture union, early functional use of the limb in the wounded patient was emphasized. 
It was not to be delayed because of wound closure, reconstructive procedures, or 
prolonged debility of parts or of the whole patient. Anything technical that com¬ 
promised early functional recovery was believed to be unimportant and a deterrent 
to total patient rehabilitation. This was exemplified in the management of the open 
tibia fracture with the walking cast and of open comminuted fractures of the 
femoral shaft with the cast brace. The lower extremity amputee was ambulated 
with an open stump in a temporary plaster socket with foot extension. Wound heal¬ 
ing by secondary intention was accepted in the upper and lower extremities, includ¬ 
ing the hand, so long as early functional use could be instituted to the injured part. 
This emphasis on functional recovery in the care of the femoral shaft fracture, for 
instance, reduced the patients time at full bed rest from months to a few weeks. 



EPILOGUE 


213 


COMMUNICATION AND CONSULTANTS 

Orthopedic surgery in wartime deals with large numbers of casualties who, by the 
nature of their injuries, require weeks or months of continuing care and rehabilita¬ 
tion. The interchange of information between the initial treating physician in Viet¬ 
nam and the receiving physicians in CONUS was vital for optimal care. But orthope¬ 
dics, as a subunit under surgery in the U.S. Army administrative system, had no way 
of direct information exchange among orthopedic elements in Vietnam, the offshore 
hospitals, and CONUS. Although orthopedic surgeons in the United States were con¬ 
stantly trying to get information to surgeons in the Republic of Vietnam about prob¬ 
lem areas, and orthopedic surgeons in Vietnam were interested in the follow-up treat¬ 
ment and progress of the patients, communication of this information was difficult. 

The information and recommendations generated during the Vietnam War by 
five surgical conferences on management of battle casualties held at various sites in 
the Pacific also circulated very slowly. These conferences were attended by physi¬ 
cians from Pacific Command, Vietnam, and CONUS, from all three services, but 
few of their conclusions about the initial and early management of battle-wounded 
patients affected the treating physicians in Vietnam, probably because of the lack of 
a full-time, traveling orthopedic consultant with the authority to effect administra¬ 
tive or professional changes in the Republic of Vietnam. During their entire year in 
the country, many orthopedic surgeons never saw another orthopedist, except the 
ones with whom they were assigned. 

We strongly recommend that in future conflicts, full-time traveling orthopedic 
consultants be available at all echelons with autonomous authority for administrative 
changes. Having orthopedic consultants in the forward area, offshore, and in CONUS 
would allow ready exchange of information and better assessment of management 
options. To have a consultant whose primary interests and training are in fields other 
than orthopedics to act as an orthopedic consultant is counterproductive, dangerous, 
and not conducive to the free flow of information or interchange of ideas. 

CONTINUITY OF CARE AND REHABILITATION 

Since in wartime a single patient may be treated by different physicians before 
arriving at a definitive treating hospital, chronological medical information about 
what has transpired during the transfer is important. But if you mention medical 
records and their administration to any combat physician who served in Vietnam, his 
discomfort index immediately goes up. In many instances, lack of an adequate clini¬ 
cal record made patient management a severe problem. The medical record for the 
patient repeatedly transferred from one facility to another usually contained consid¬ 
erable administrative data repeated over and over but very little medical informa¬ 
tion. We believe that some type of electronic cassette recorder should be placed into 
the evacuation system on which comments can be made and from which the infor¬ 
mation can be retrieved about what has happened previously to the patient. The cas¬ 
sette, designated for medical information only, would have no erasure button. It 
could easily accompany the patient like a dog tag around his neck, making the infor¬ 
mation constantly available along the evacuation chain. By using the cassette, the 


214 


ORTHOPEDIC SURGERY IN VIETNAM 


status of a peripheral nerve injury at the time of debridement in Vietnam, for exam¬ 
ple, could be immediately available to the physician treating the patient in CONUS. 
Standardization of playback capability is needed. Such a system would certainly re¬ 
sult in a more complete medical record and eliminate poor penmanship as a factor. 

Once a patient reached the definitive hospital in CONUS, the question arose as 
to whether this was really the definitive hospital for him. Was this hospital responsi¬ 
ble for his long-term rehabilitation, both physical and psychological? Was this hos¬ 
pital capable of managing all his needs until discharge from the service or return to 
duty? These questions were but some of those related to the administrative aspects 
of the patients’ injuries that concerned all orthopedic surgeons treating long-term, 
severely injured patients. Throughout the entire war, the problem of hospital re¬ 
sponsibility was never resolved. 

Two types of Army units and the Veterans Administration system were in the 
group of definitive hospitals that cared for the wounded who faced long hospitaliza¬ 
tion. The military system had a Class I or station hospital and Class II or general or 
teaching hospital. The Veterans Administration also had hospitals throughout the 
country that varied considerably in their individual capabilities. In the administra¬ 
tion of the evacuation system, orthopedic patients were initially sent to a military 
hospital close to their home. This could be a Class I or Class II hospital with an or¬ 
thopedic service and a physical therapist. 

Col. Raymond Bagg has pointed out that patients who have no chance of re¬ 
turning to active duty should be rapidly separated from the service. He advocated 
that this separation be accomplished as soon as possible because of the financial 
loss to the patient. For instance, a PFC U.S.M.C. with a bilateral above-knee ampu¬ 
tation would not be capable of being returned to duty. In this case total CONUS 
hospitalization could amount to six to seven months. Veterans Administration com¬ 
pensation would amount to $638 per month during the Vietnam War, while active 
duty pay during the same time would be $180 per month. This pay differential 
amounts to about $3,092 for over six months of hospitalization. 

Based on finances alone, certainly early separation is indicated. However, if this 
change from military to civilian status changes rehabilitation relationships or goals 
or results in administrative transfer, greater loss may result in the future. Severely 
injured patients need all the support we can provide since they are relatively fragile 
for a considerable time after a combat-related injury. Administrative changes that 
increase financial reward but also increase instability may be counterproductive. In¬ 
discriminate and repeated transferring of patients with changes of physician and 
therapist after the vital process of rehabilitation has been instituted reduces its ef¬ 
fectiveness. As soon as the patient’s physical condition allows, he should be sent to 
a specialized treatment center for definitive care. 

The Army’s Class I hospitals were frequently staffed by physicians who were in 
military service for only two years. Most of these physicians had one year in the Re¬ 
public of Vietnam and then one year in a Class I hospital, or vice versa. The pres¬ 
ence of an orthopedic surgeon for only one year in the management of complex or¬ 
thopedic injuries injected dissimilarities in training, lack of experience, and limited 
continuity of care into the situation. These men, although fully trained, Board-certi- 
lied and Board-qualified, were caring for complicated cases in a relatively isolated 
system with only minimal experience. 


EPILOGUE 


215 


The Class II hospitals were adequately staffed with medical and paramedical in¬ 
dividuals but had limited beds and holding facilities. In addition, they were unable 
to receive, treat, and completely rehabilitate all the orthopedic casualties from 
Vietnam. Thus there were frequent transfers of patients from Class I to Class II 
hospitals and from Class II medical centers to the Veterans Administration system 
in a haphazard fashion based on administrative requirements. The transfer usually 
occurred in the middle of the rehabilitative process and was dictated by bed re¬ 
quirements, transfer or discharge of medical or paramedical personnel, or the pol¬ 
icy to get the patient as close to his home as possible. These transfers interfered 
with rehabilitation, introduced a new treating team to the patient, and frequently 
changed the rehabilitative goals. 

In any decision concerning rehabilitation of orthopedic patients, occupational 
and physical therapists are essential. In most military hospitals the occupational 
therapist became an upper extremity therapist, while a physical therapist concen¬ 
trated on the lower limb. These two groups were involved, daily or several times 
daily, in the treatment of each patient. These were the individuals who implemented 
and modified the early functional use of the damaged limb concept mentioned previ¬ 
ously. The physical therapists were directly concerned with the lower extremity am¬ 
putee from early ambulation in the plaster-of-Paris socket to wound closure to 
definitive prosthesis. In the patient with the cast brace for femoral shaft fracture gait 
training, muscle training and encouragement were required. The occupational thera¬ 
pists were concerned with training the patients in the activities of daily living, with 
peripheral nerve testing, and with early prosthetic training of the upper extremity 
amputee. In addition, they fabricated splints, tested patients, and helped patients 
with peripheral nerve injuries reeducate their upper extremities to perform volun¬ 
tary motion effectively. Such activities were carried out not just in CONUS but in the 
Republic of Vietnam and in offshore hospitals as well. These innovative, interested, 
intelligent individuals were of immense value to both patient and physician, and dis¬ 
ruption of the relationship they had developed with the individual patient and of the 
course of rehabilitation that they had started with him was harmful to his progress. 

The lack of continuity and its adverse effects upon rehabilitation were a serious 
medical problem throughout the war in Vietnam. The role of patient rehabilitation in 
the recovery process requires further study and better application. To avoid the pro¬ 
fessional problems that I have mentioned, we recommend the development of the 
professional center concept as it existed in World War II. Because they would be 
staffed by medical, paramedical, and rehabilitative personnel, these professional cen¬ 
ters could become definitive care centers in CONUS to manage patients completely 
from reception from overseas to definitive disposition. Whether the center is a U.S. 
Army hospital or a Veterans Administration hospital makes little difference. That is 
an administrative decision. But this approach would eliminate the indiscriminate 
transfer of a combat-wounded soldier from hospital to hospital and team to team, re¬ 
ducing his motivation and negatively affecting the entire rehabilitative process. 

The dispersion of orthopedic patients throughout CONUS complicated even col¬ 
lecting the comprehensive data needed to study the care and rehabilitation of ortho¬ 
pedic patients, always difficult in wartime. When the group of orthopedic surgeons 
was brought together in 1972 to write this history, we knew it would be an immense 
undertaking, not merely because of the sheer number of words but because of our 


216 


ORTHOPEDIC SURGERY IN VIETNAM 


desire to write a history useful for orthopedic surgeons in the day-to-day practice. 
Our statements and conclusions had to be supported by scientific data, but, because 
of the difficulty of retrieving the information we needed, most of the clinical data in 
the chapters came from records collected by individual authors rather than from a 
central retrieval system. The establishment of centers for hand, peripheral nerve, 
amputee, and other medical problems in significant numbers would make it possible 
in the future to collect data and alter treatment modalities on the basis of past expe¬ 
rience. A center concept for complex orthopedic injuries is essential if usable man¬ 
agement options are to be learned in future wars. So long as these complex orthope¬ 
dic cases are widely dispersed, clinical data retrieval will be, at best, haphazard. 

This chapter has covered in a general way the practice of orthopedics during the 
era of the war in Vietnam. It contains lessons learned, lessons relearned, and some 
lessons that we believe should be forgotten. In addition, it mirrors our frustrations 
regarding dissemination of professional orthopedic information within the evacua¬ 
tion system and our immense concern for our patients and their total rehabilitation. 
Our recommendations to improve the system are made because of this concern and 
our desire to improve patient care. 


INDEX 


A-rations, 3 
Ablation, 36, 97, 131 
Achilles tendon, 90 
Air conditioning 

help in care of wounded, 17 
in surgical suites, 2, 4 
Ambulation 

after amputation, 137, 141^42, 147-48, 150 
in CONUS, 30-32, 36 
examples of, 86-87, 93, 97, 101 
after leg fractures, 44-47, 52 
American Orthopedic Association, 126 
American soldier, condition of, 3,17, 21 
Amputation 
causes of, 8,131 
incidence of, 28, 36, 131-32 
with leg fractures, 39, 41, 43 
management of patients, 132-34, 136-37,190 
problems of transfers, 190 
recommendations, 151-52 
treatment in CONUS hospitals, 192-93 
with wounds of the foot, 85-87, 137 
hindfoot, 93-94, 96 
midfoot, 97-98 
toe, 100-102 

with wounds of the hand. 64 
with wounds of the knee, 146-47 
Amputation types 

Chopart amputation, 97-98-105, 138, 149 
elbow 

above elbow, 146 
below elbow, 144-46 
Ertl-type revision, 141, 148, 151 
foot, 137-38 
hand and wrist, 144 
knee 

above knee, 133, 143^44, 147 
below knee, 133, 139, 142^43, 146-47 
Lisfranc amputation, 138, 144 
Syme’s amputation, 97-98, 100, 105, 133, 
137-39, 148—49 
Amputees 

recommendations for, 207-09, 212 
rehabilitation of, 190-91, 196-97 
sports for 

riding, 204-05 
skiing, 198-203 
swimming, 203-04 

treatment of, 132-33, 136-37,146-48, 150-52 
Anastomoses, 168,170 
Anatomy, knowledge of, 23 


Anesthesia 
induction of, 5, 126 
during operations, 113, 122, 124-25 
Angulation, 30-31 
Ankylosis, 114, 118-19 
Antibiotics 
effects of, 10-12 
supplementary use, 35-36, 40 
use of, 211-12 

use with joint wounds, 107, 110-11, 115 
use with puncture wounds, 90-91 
Arapahoe Ski Basin, Colorado, 198, 201 
Army medical centers, 171,178-80. See also 
United States Army hospitals. 

Army of the Republic of Vietnam, wounds in, 7-8 

Arterial bleeding, 133 

Arteries/blood supply, 90-91, 93, 96 

Arthrodesis, 77, 80, 123,125-27,129 

Arthroplasty, 101, 126 

Arthrotomy, 107, 110-11, 114, 119, 121 

Bacterial flora, 9, 11 
Bamboo stakes, effects of, 87-88 
Blair, Col. John D.. 56 
Blast injuries, 5, 43 
Blood transfusions, 3-5, 40 
Bone grafting, 47, 52 
with wounds of foot, 85 
with wounds of hand, 69, 72, 77 
Bone loss 

with leg injuries, 47, 52 
with wounds of the hand, 63, 72 
Booby traps, 7, 131, 133 
Brooke Army Medical Center, San Antonio, 
Texas 

results from wounds of femur, 31-32 
results from wounds of foot, 98,100 
results from wounds of leg (tibia), 46-47 
techniques, 180 
tests for sensibility, 178 

treatment of nerve injuries at, 157,160-61,171, 
176 

Brown, Col. Paul W., 182 
Bunnell, Dr. Sterling, 55-56 

Calcaneus with wounds of the foot, 85-87, 90-91, 
93 

Capsule joint wounds, 112-13, 121-22 
Casts 

bivalving of, 43-45 
cast brace, 30-32, 35-36 


218 


INDEX 


Casts—Continued 

long leg cast, 44^16, 52 
short leg cast, 45-46, 52 
spica cast, 26-27, 29, 31, 133 
use of, 112-13,133 
Casualties, 1 

Catheters, 3-4, 11,107, 122; in cases of causalgia, 
160-61 

Causalgia, 28, 156 
history and incidence of, 158-59 
treatment of, 158-61 
Cavitation, 7-8 

Chemical blocks, in treatment of causalgia, 159-60 
CINCPAC Surgical Conferences, 12, 110-11, 125, 
134 

Clark Field, U.S. Air Force Base, Philippines, 2, 
6,9 

Cellular necrosis, 5. See also Necrosis. 
Communition, 63, 69, 91 
Communications, 3 

problems concerning injuries. 44, 155, 213-14 
problems concerning treatment, 196, 207-08 
Compartment syndromes, 41. See also Fractures 
of the femur; Fractures of the tibia. 
Complications of wounds, 44, 47 
Contamination, as factor in healing, 13, 35, 40, 60, 
84-85, 105 

CONUS (continental United States), 1-2, 6, 9, 
212-14 

evacuation of patients to, 27, 29 
rehabilitation of patients, 113, 121-22, 191-94 
treatment of amputees, 132,136, 139, 142, 
150-51, 192 
Convalescence, 5-6 
Curtis, Dr. Raymond M., 56, 179-80 

Debridement 

after amputation, 138, 142, 144, 149-50, 152 
with femoral fractures, 22-23, 26, 28-29, 32, 35 
as general technique, 211-12 
history of, 6 

use in Vietnam, 8, 9,13 
use in World War II, 10, 22, 39 
with vascular/nerve injuries, 155-56, 166 
after wounding, 131-34 
with wounds of the foot, 83-85, 87, 90-91, 94, 
101,102, 105 

with wounds of the hand, 60, 63, 67,69, 72, 80 
with wounds of the joints, 107, 110-11 
hip, 121-23 
knee, 112, 114, 118 
shoulder, 123-25 

with wounds of the leg, 41, 43, 46, 52 
Dehydration, 3, 112, 134 
Delayed primary closure 
after amputations, 133-34, 136,139, 144, 150-51 


Delayed primary closure—Continued 
difficulties with, in 
foot injuries, 86 
hand wounds, 64,67 
joint wounds, 110, 113, 125 
leg injuries, 39^10, 43-44 
nerve injuries, 166 
thigh wounds, 26, 29 
technique of, 6 

use in Vietnam, 22 
use in World War II. 21-22, 39-40 
wound management, 211-12 
Deltopectoral flap, 69 
Desault, Pierre Joseph, 6 
Desensitization techniques, 165 
Diarrhea, 3 

Dirt, as factor in infection, 7 
Dislocations 

basilar thumb joint, 60, 63 
carpometacarpal, 60, 63, 72 
intermetacarpal, 60 
metacarpophalangeal joint, 72, 77 
Disseminated intravascular coagulopathy (DIC), 5 
Distal blood flow, 26, 28, 36, 132 
Dorsum/dorsalis pedis, 96-97 
Drainage of wounds, 10-11 
excessive drainage, 26, 35 
with fractures of femur, 21 
with hip wounds, 122 
improved with cast brace, 30 
with shoulder wounds, 125 
with thigh wounds, 28 
Dressings, 60, 85 

“Dust Off”(medical evacuations), 3 

Effectiveness of medical treatment, 7-8 
Elevation of extremities, 23, 60, 63 
Endemic disease, 1 

Evacuation from combat areas, 2-3, 8-9 
to CONUS, 26 

to hospitals, 40, 44, 112, 125, 131-34, 136, 151 
priority and procedure, 27, 29, 63, 67, 80 
problems of, 190-91 
Excision of tendons, 72, 76 

Fascia, 8 

excisions of, 28, 40-41,60, 124 
incisions, 40-41 
Fascial decompression, 41,43 
Fascicles, 183 

Fasciectomy/fasciotomy, 8, 10, 211 
Fat embolism, 5 
Feagin, Maj. John, 110-11 
Femoral artery, 23, 26 

Femoral fractures. See Fractures of the femur. 
Fibula. See Fractures of the tibia. 


INDEX 


219 


Field dressings, 3 

Fitzsimons General Hospital, Denver, Colorado 
follow-up study at, 182 

rehabilitation and treatment of amputees, 132, 
138-39, 141-42, 146-48, 189, 192 
use of sports in treatment, 198, 202-06 
treatment of wounds at: 

femoral shaft fractures, 31 
hindfoot wounds, 94, 96 
hip joint wounds, 122 
knee wounds, 113—15 
midfoot wounds, 97-98, 100 
nerve injuries, 157 
neurolysis, 165 
shoulder wounds, 127, 129 
toe wounds, 102 
Fixation of fractures 
foot wounds, 85, 101 
hand wounds, 63, 72, 77 
with Kirschner wires, 63-64, 73, 77, 97 
with Steinman pin, 26-27, 31-32, 39, 113, 125 
Flexion, 167, 171, 184-85 
Foot wounds, 102-03, 105. See also Amputation; 

Debridement; Fitzsimons General Hospital. 
Fracture management 
in Vietnam, 22, 32, 36 
in World War 11,22 
Fractures, 5-7, 9, 27-28 
Fractures of the femur 

breakdown and bone loss, 29, 32 
hip wounds, 123, 133 
history of treatment, 21, 27-28 
serious nature of, 21, 27 
treatment of, 21,26-28, 30-31 
Fractures of the tibia 
history of treatment, 3940 
incidence of, 3940, 4345 
nature of wounds, 28, 39 
use of cast brace, 30 

Gaenslen incision, 91 
Ganglion blocks, 161 
Gangrene, 12, 16 
Grafting 

bone grafts, 47, 52, 69, 72, 77, 85 
iliac grafts, 72, 127 
nerve grafts, 167, 169-70, 184 
technique of, 9-10 

tendon grafts, 77, 171. See also Bone grafting; 
Nerve injuries. 

Gram-negative and positive organisms, 36 
Granulation, 118 
Grenades, 133 

Hall, Col. Robert M.. 11 

Hampton, Dr. Oscar P., Jr., 32, 39, 43, 93-94, 134 


Hand splints, 60. See also Splinting devices. 
Hawaii, 110, 112 

Heaton, Lt. Gen. Leonard D., 56 

Helicopter, 1,3, 17 

Hematocrit, 44 

Hemorrhagic shock, 5 

Hemostasis, 60, 84-85 

High-velocity wounding agents, 7-8, 40 

Hindfoot wounds, 90-92. See also Debridement. 

Hip wounds 

involvement of femoral head (blood supply), 
119,121-23 

morbidity/mortality, 119, 122-23 
treatment of, 121-23 
Hospitals 

Classes I and II, 214-15 
equipment and strengths, 1-3 
locations 

in CONUS, 6, 27,65-69, 80, 85 
off-shore, 67-69 
Hypoxemia, 4-5 

Ilium, 122-23 
Immersion foot, 16 
Immobilization 
of joint wounds, 107, 110, 113 
of limbs, 6, 26, 3940, 77 
Implants, 76-77 
Incisions 
amputations, 133 
foot wounds, 91, 93, 96,102,105 
hand wounds, 60 
joint wounds, 121-22, 124 
Infection, incidence of, 212 
foot wounds, 83, 88, 90, 93, 102 
hip wounds, 121-23 
joint wounds, 107, 110,113-15,118-19 
shoulder wounds, 124, 129 
Intra-articular drains, 107, 112, 118 
Intra-articular fractures, 107, 112-15, 118, 129 
Intramedullary nailing, 32, 35 
Intravenous fluids, 40 
Irrigation of wounds, 2, 28, 88, 107 

Japan 

convalescence in, 2, 6, 9 
hospitals in, 4546, 111-12,191 
Jet lavage, 1 

John Hay Air Base, Philippines, 110 

Joint wounds, history of treatment, 107, 110-11 

Jump, Larry, 198 

Kirschner wires, use of, 63-64, 73, 77, 97, 101, 113, 
121, 138. See also Fixation of fractures. 

Knee wounds 
causes of, 113-15, 118 


220 


INDEX 


Knee wounds—Continued 
closed injuries, 111-13 
hematogenous arthritis, 118-19 
open wounds, 111-12 
pyogenic arthritis, 118-19 

Lacertus fibrosis, 8 
Lactic dehydrogenase (LDH), 5 
Laparatomy, 5 
Lavage, 1, 8, 85 

Leg, penetrating wounds of, 39^10 
Letterman Army Medical Center, San Francisco, 
47.56 

Littler. Dr. J. William, 56 
Long leg cast. See Casts. 

Lucks, Edwin. 198. 202, 205 

M16 rifle, 8 
Malaria, 1 
Mandelamine, 12 

Medical Civic Action Program (MEDCAP), 16-17 

Medical Corps. 192, 209 

Medical discharge, 136-37 

Melioidosis, 13, 16 

Metabolism. 5 

Metz, Lt. Gen. Charles W., Jr., 56 
Microbiology, 13 
Microorganisms. 12 

Midfoot wounds, 96-97. See also Debridement; 

Fitzsimons General Hospital. 

Military surgical practices in U.S. Army, Vietnam 
(USARV), 11 

Mines, 7; injuries caused by, 43,131,133,149 
Missiles as wounding agents, 7-8, 40 
Morbidity rate, 39, 65, 83, 102. 105, 119, 121 
Motion, prevention of loss, 69 
Motivation after amputation, 195, 197-98. 204-05, 
207-08. See also Rehabilitation. 

Muscles. See specific areas (e.g., foot, hand, hip, 
joints). 

NATO Emergency War Surgery Handbook, 6, 9, 
11.110,132-33 

Necrosis, 5, 29, 41, 44, 46, 63-64. 67 
with amputation, 138 
with wounds of the foot, 84-85. 90-91 
with wounds of the hip, 119, 121, 123, 212 
with wounds of the shoulder, 124-25 
Neel. Maj. Gen. Spurgeon, 3, 17 
Nerve injuries, 44 

peripheral nerve injuries, statistics, 155-58, 
166-67, 174-76, 182 
specific nerve injuries, 182-84 
surgical treatment of, 168-71 
techniques used, 167-69 
treatment of, 156-57, 160-61, 183-86 
wounds of the foot, 83, 85 


Neurolysis, 169, 183 
Neuroma, 161 
Neurorrhaphy, 166, 168 

Newton D. Baker General Hospital, Martinsburg, 
West Virginia, 56 
Nitrous oxide, 1 

Nonunion of fractures, 32, 39, 44 
Nurses, 3, 196 
Nursing units, 2 

106th General Hospital, Yokohama. Japan, 9. 32, 
47,132; experience with amputations, 132, 
136,138-39 
O-positive blood. 3 

Oakland Naval Hospital. Oakland, California. 143 
Occlusive dressings, 6, 9, 40, 44, 112-13 
Occupational therapists, 179, 215 
Omer, George E.. 157, 168-69 
Operating room, 3. 22-23, 40 
Orr, Dr. H. Winnett, 6, 21 
Orthopedic hand service, Walter Reed, 56 
Orthopedic surgeons 
assistance to civilians, 16-17 
lack of numbers, 2-3 

recommendations about, 209, 213, 215-16 
responsibilities of, 6, 8, 11 

care of hand wounds, 56, 60 
femur/thigh. 26-27.36 
joint wounds, 123-24 

treatment of amputees, 132. 133, 136-37, 192-93 
Orthopedic surgery conference, 110 
Orthopedic training, 192 
Osteomyelitis, 31. 35, 46^17, 91. 119 
Osteotomy, 35 
Oxygen, use of, 1,5 

PACOM (Pacific Command) hospitals, 11-12, 

122,126, 132, 151 

"Paddy foot.” See Immersion foot. 

Palsy, 180, 185 

Patients in Vietnam, 26-28 

Peacock, Capt. Erie E.. Jr., 56 

Pedicle flaps (abdominal), 64. 67, 69, 86-87 

Penicillin 

discovery and use of, 10, 12, 111 
limitations of, 12-13 
Penicillin-streptomycin regimen, 12 
Phantom pain, 165 
Philippines, 110. 112, 191 
Physiatric methods, 190, 192-93 
Physical modalities (nerve problems), 165-66 
Physical therapists, 6, 179, 215 
Physical therapy, 8.166 
Plantar area of foot, 88, 90-91, 102-03, 105 
Plaster of Paris immobilization, 40,43 
Pneumatic torniquet. 60 


INDEX 


221 


Postoperative units, 2 
Prosthesis 

after amputations, 136, 138-39, 141-43, 146-47, 
150-51 

with specific injuries, 87, 123, 126, 146 
Prosthetic devices, 146^18, 150-51, 180, 187 
Psychogenic pain, 165 
Psychological factors, 6, 8, 195 
Pulleys, use of, 76 
Pulmonary disease, 4-5 
Puncture wounds 
of the foot, 87-88, 90 
of the knee, 113-14 
Punji sticks, 113-15 

Qui Hua Leprosarium, Vietnam, 17 

Radiographs of wounds, 31, 39-40, 43, 60, 83, 148 
Radiological facilities, 1, 3 
Ratio of killed to wounded, 7 
Reconstruction of hand, 63, 68-69 
Red Cross personnel, 199, 203 
Rehabilitation, 6, 36 

of combat-wounded amputee, 146—17, 189-92 
importance of motivation, 184, 191, 194-95, 

197, 203, 205, 207-08 
recommendations, 212, 214-15 
role of personnel and policy, 208-09 
sports as therapy, 203-06 
Rehabilitation medicine, 189-90 
Republic of Vietnam, 1, 213 
Resuscitation, 3-4, 22 
Riding as rehabilitation, 204-06 
Ringers lactate, 3 

Schaeffler, Willie, 198 
Secondary closure 
after amputations, 139, 142, 144, 150 
after fractures, 29, 39, 44-45 
Secondary intention wound healing, 44-46, 52,69, 
86, 90, 122,212-13 
Secondary operative procedure, 64 
Secondary wound care, 9 
Self-inflicted wounds, 8, 100-101 
Sensory functions 

follow-up study of, 182-83 
tests of sensibility, 178-80, 185 
Sepsis, 12-13, 26, 36, 43, 45, 47, 72, 212 
Septicema, 8 
Serum enzymes, 4-5 
Shoulder/upper arm wounds 
muscle viability, 124 
neurovascular damage, 123-24 
treatment of, 124-27,129 
Skiing, 198-203. See also Rehabilitation. 

Skin flaps, 134, 138, 149-50 


Skin grafts, 45-46 

after amputations, 143-44, 146, 149, 151 
closure of wounds, 67-69 
joint wounds, 113-14, 122, 125 
Skin traction, 133-34,139, 143-44, 151 
Small arms, 7 

Soft tissue injuries, 26, 47, 52, 112 
Splinting devices, 3, 8, 26, 29, 39—10, 113 
Splints, 39-10, 43 
amputations, 133-34 
foot wounds, 85-86 
joint wounds, 110,113 
Staff specialists, 3 
Stanek, Dr. William F., 198, 201 
Steinman pin, 22, 26-27, 91, 113, 121, 138 
Streptomycin, 12 
Sulfa crystals, 10 
Sulfamilamide drugs, 10-11 
Surgeon General, 4, 193, 209. See also Heaton, Lt. 
Gen. Leonard. 

Surgeon General’s Office, 208-09 
Surgeons, 3-4,12, 22, 122-23 
Surgical procedures, 3-4 
Surgical training, 192-93 
Sutures, 9-10, 167-68, 183-85 
Swimming, 203-04. See also Rehabilitation. 
Sympathectomy, 160-61 
Syndromes, nerve damage 
Horner’s syndrome, 161 
Leriche’s posttraumatic pain syndrome, 158 
shoulder-arm-hand, 158 
Sudek’s atrophy, 158 
Synovectomy, 115, 118-19 
Synovium, 11-12, 114-15 

Table of Organization and Equipment (TO&E). 
2-3 

Talectomy, 91 

Talus (wounds of the hand), fractures of, 90-91 
Tarsal wounds of foot, 85, 87, 93, 96-98 
Tarsus, 93 

Technicians, enlisted, 3 
Tendon injuries 

history of treatment, 72, 76 
incidence of, 72, 77, 93,170-71 
Tendon transfers, 171, 174, 176-78, 184-85 
Tet offensive, 191, 194 
Tetanus, 12, 16, 40, 90 
Therapeutic antibiotics, 11-12,16. See also 
Antibiotics. 

Thigh, penetrating wounds of, 21-22, 26, 28-29 
Tibia. See Fractures of the tibia. 

Tissue injury, wounds of the hand, 64, 67 
Tobruk splint, 26, 29 
Toe wounds 
claw toes, 101 



222 


INDEX 


Toe wounds—Continued 

importance of great toe, 100-101 
treatment of, 98,100-101 
Tourniquet, 40, 43 
Toxicity, 12, 43 
Traction 

with femoral fractures, 23, 29, 31 
with fractures of tibia, 39 
Transfusions, 3, 23. 40 
Trauma, 5 

from evacuation, 26, 29 
from surgery, 132, 137,144, 149 
Treatment of femoral fractures, 21, 23, 27, 29 
Triage, 3. 22, 40 

Tripler Army Medical Center, Hawaii, 9,45 
Trueta, Joseph, 6, 9 

Union of fractures, 32, 44 
United States Army hospitals 
85th Evacuation Hospital, Qui Nhon, Vietnam, 
8, 110, 155 

106th General Hospital, Yokohama, Japan, 9, 
32,47, 132, 136,138-39 
Brooke Army Medical Center, San Antonio, 
Texas, 31-32.46^17, 98, 100, 157, 160-61, 171, 
176, 178, 180 

Camp Zama, Japan, 133, 136, 138 
Fitzsimons General Hospital, Denver, 

Colorado. See Fitzsimons. 

Letterman Army Medical Center, San 
Francisco, 47, 56 

Newton D. Baker General Hospital, 
Martinsburg, West Virginia, 56 
Valley Forge General Hospital, Pennsylvania, 
11, 16,31,69, 132, 137, 141^42 
Walter Reed General Hospital, Washington, 
D.C., 56, 80,148, 179-80 
United States Army Medical Command, Japan, 

27 

United States Army Surgical Research Team, 4 

Valley Forge General Hospital, Pennsylvania, 11, 
16, 31,69; treatment of amputees at, 132, 137. 
141-42 


Vascular injuries 
with amputations, 131 
with femoral fractures, 26, 28 
with foot wounds, 83-84 
repair of, 36, 155-56 
Vascular surgeons, 26-27 
Veterans Administration, 182, 209, 214 
Veterans Administration hospitals 
history of, 185, 190, 193 
treatment of amputees at, 136-37, 141, 147 
Veterans Administration Prosthetics Research 
Unit. 147 

Walter Reed Army Institute of Research 
(WRAIR), 12 

Walter Reed Army Medical Center (Walter Reed 
General Hospital), Washington, D.C. 
hand and orthopedic service at, 56, 80, 148, 
179-80 

War surgical techniques, 166, 168, 180. 183 
Weight-bearing methods, 39—40, 46 
Whelan, Col. Thomas J., MC, 12,126 
Willems, Dr. Charles, 107 
Woolverton, Mary, 204 
Wound closure and control 
fractures of femur, 22, 35 
hand wounds, 64, 67-68 
thigh wounds, 29 

Wound infections, 10-11, 13, 16-17, 35-36 
Wound management, 60, 64, 68, 77, 131-32, 208, 
212 

Wounded soldiers in Vietnam, 3, 16-17 
Wounding agents, 131 
Wounds of the hand 
incidence of, 55-56 
management of, 56, 60, 63, 184 
Wrist injuries, 77 

X-ray technique, 148. See also Radiographs of 
wounds. 

Zone of the Interior 
Vietnam, 156 
World War II. 22, 56, 93 


☆ U.S. GOVERNMENT PRINTING OFFICE: 1994 304-295 











































